Novel Method of Treating Macular Degeneration Using Botulinum Toxin-Based Pharmaceuticals

ABSTRACT

Formulations and methods of treatment are disclosed for prevention and/or treatment of visual loss from age-related macular degeneration. The disclosed formulations include botulinum neurotoxin. The disclosed formulations may be applied to an intraocular or extraocular region of a patient. If applied to an extra ocular region of a patient, the botulinum-based pharmaceutical formulation may then be transported to the intra-ocular region of the patient, allowing the active ingredient(s) to penetrate into the choroid, neuro-retina, and/or retinal pigment epithelium without direct injection into the eye, eliminating risk of retinal detachment, retinal break, retinal hemorrhage, and blindness. The methods described herein allow for increased blood flow to the choroid, which improves removal of metabolites and intra retinal fluid and also serves to arrest, reverse and/or delay early and later stages of age-related macular degeneration.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation-in-part of and claims priority toU.S. patent application Ser. No. 15/834,491, filed Dec. 7, 2017, whichclaims priority to U.S. Provisional Application Ser. No. 62/431,512,filed Dec. 8, 2016, U.S. Provisional Application Ser. No. 62/449,914,filed Jan. 24, 2017, and U.S. Provisional Application Ser. No.62/533,961, filed Jul. 18, 2017, the contents of which are eachincorporated by reference herein.

BACKGROUND

Macular degeneration is a major cause of human blindness, generallyoccurring in the population over 50 years in age. The condition isgenetic with offspring having about a 50% chance of inheriting aclinically significant condition form a parent who became legally blindfrom the affliction. Macular degeneration accounts for up to 70% of theirreversible blindness in the United States and is one of the mostcommon problems encountered by Ophthalmologists. Worldwide, theprojected number of people with age-related macular degeneration in 2020will be 196 million and is predicted to increase 288 million in 2040.Reducing the rate of disease progression and improvement in durationpotency and sustainability of current therapies would be very useful inreducing costs to national and state insurance carriers.

SUMMARY

Novel formulations and methods of treating and possibly preventingvisual loss from macular degeneration by administering botulinumtoxin-based pharmaceuticals are disclosed herein. Administration of thedisclosed formulations can be intra-ocular or extra ocular, and, in someembodiments, may include subcutaneous, sub-muscular, intraneural,topical, intraosseous, and/or interfacial injection. As used herein, theterm “intra-ocular” refers to the application of formulation directly tothe globe of the eye and the term “extra ocular” refers to theapplication of formulation to regions other than the globe of the eye(e.g., to the eyelid or to the orbital). In cases where extra ocularinjections are employed, complications of intra-ocular injections can beavoided. In some embodiments, repeated injections may be employed tokeep biologic effect current and operational. Improvements in vision canbe subjectively reported after treatment according to the disclosedmethods and, in some cases, SD-OCT, fundoscopy, or other imagingtechniques may be used to observe physical changes in the physicalstructure of the eye.

In some embodiments, an injection may penetrate the orbit and macularvia pathways which do not cause a weakening of the extra ocular muscles,thereby avoiding diplopia, ptosis, and other neuromuscular effects whichcan create complications. As explained below in detail, the disclosedformulations and methods may be designed to target one or more of thefollowing tissues: choroid, neuro retina, retinal pigment epithelium(RPE), peripheral nerves entering the eye, and/or other associatedtissues. The disclosed formulations and methods may, in someembodiments, be used to treat both exudative forms of maculardegeneration (i.e., with intra retinal fluid, blood, or sub-retinalfluid or blood and non-exudative forms, which can lead to geographicatrophy).

Prior to administering the disclosed formulations to a patient, aclinical assessment may be made by a qualified medical practitioner toevaluate whether treatment according to the disclosed methods isappropriate. Clinical assessment may be made based on one or more of thefollowing: family history, fundus inspection using photography, SD OCT,with careful evaluation of the status of the retinal pigment epitheliumfor defective signs, including but not limited to presence of pigment infundoscopy, pigment migration anteriorly into the neuro-retina(intra-retinal hyper pigment), presence and volume of drusen, focalintra retinal hyper reflection, sub drusenoid deposits, sub-drusenoidhyperreflectivity, dynamic reduction in drusen volume, second eyestaging for severity, hypo reflectivity, choroidal neovascularization,hypo pigmentation, discontinuity and disappearance of OCT reflectivitylines (e.g., IS-OS, external nuclear layer, RPE layer), retinal andchoroidal thickness or associated components, dynamic changes in anymeasurements, thickening of reflectivity lines, cyst formation, and anyconfiguration of fluid formations. In some cases, activation of the RPEmay be a risk factor for macular degeneration progression and anassessment may be made for progression risk based on one or more of:anatomic pathologic findings, history, and tempo of disease progressionand status of the second eye.

As explained in detail below, the disclosed formulations and treatmentmethods may delay degeneration of the RPE, preserve photoreceptors,treat or prevent high risk leakage, treat and preventneovascularization, prevent cell apoptosis, treat and prevent RPEactivation, treat and prevent RPE migration, treat and prevent sheetdistortion in the RPE, prevent geographic atropy, prevent retinalatrophy, prevent loss of rods and cones, convert wet stage to dry stage,preserve vision and/or restore vision.

BRIEF DESCRIPTION OF THE DRAWINGS

FIGS. 1A-1C are illustrations of the macula of an eye. In particular,FIG. 1A illustrates a healthy macula, FIG. 1B illustrates a maculasuffering from dry macular degeneration, and FIG. 1C illustrates amacula suffering from wet macular degeneration. Wet macular degenerationis often associated with rapid loss of vision and dry maculardegeneration is associated with slow progression loss of vision. Formsof dry macular degeneration can also indicate risk for conversion to awet (exudative state) and should be followed by the clinician over time.

FIG. 1D is an image obtained using optic coherent tomography (OCT),showing breakage in continuity of the retinal pigment epithelium (RPE),as would occur in early-stage age-related macular degeneration.

FIG. 2 is an OCT image illustrating a dense disciform fibrotic scar inend stage macular degeneration. Portions of the scar illustrated in FIG.2 demonstrate geographic atrophy (GA), with attendant loss ofphotoreceptors.

FIG. 3 is an OCT image illustrating leakage of fluid through the RPEunder the neuro retina in a case of wet macular degeneration.

FIGS. 4A-4C illustrate the hexagonal structure of the RPE.

FIGS. 5A-5F illustrate disruption of membranes, sub membranecondensation, alteration of hexagonal shapes of the structure, RPEautolysis, stress fiber formation from actin associated with maculardegeneration.

FIG. 6 illustrates a top view of a human dissection orbit withpenetration of nerves and vessels into the posterior pole under themacula.

FIG. 7 illustrates extra-ocular administration followed by nervepenetration and transcytosis with eye penetration.

FIG. 8 shows a schematic drawing of the glomerular barrier.

FIGS. 9A-9F illustrate OCT images obtained from patients treated withthe disclosed therapeutic formulations, according to the disclosedmethods. Enhancement effects of anti-VEGF agents are also visible inFIGS. 9A-9F.

FIGS. 10A-10B illustrate OCT images obtained from a patient treated withthe disclosed therapeutic formulations, according to the disclosedmethods.

FIGS. 11A-11D illustrate OCT images obtained from a patient treated withthe disclosed therapeutic formulations, according to the disclosedmethods.

FIGS. 12A-12C illustrate OCT images obtained from a patient treated withthe disclosed therapeutic formulations, according to the disclosedmethods.

FIGS. 13A and 13B illustrate OCT images obtained from a patient treatedwith the disclosed therapeutic formulations, according to the disclosedmethods.

FIGS. 14A-14D illustrate stress fibers in RPE cells.

FIGS. 15A and 15B illustrate OCT-A images obtained from a patienttreated according to the disclosed methods.

FIG. 16 illustrates an OCT-A image obtained from a patient treatedaccording to the disclosed methods.

FIG. 17A illustrates numerous OCT-A images obtained from a patienttreated according to the disclosed methods.

FIG. 17B illustrates an exemplary pteryo palatine injection, inaccordance with some embodiments of the subject disclosure. The imagesshown in FIGS. 15A, 15B, 16, 17A, and 17B illustrate increased bloodperfusion based on red blood cell movement in the parafoveal region.

FIG. 18A illustrates images of a patient's eye after treatmentadministered in accordance with some embodiments of the subjectdisclosure.

FIG. 18B illustrates an OCT-A image obtained from a patient treatedaccording to the disclosed methods.

FIG. 18C illustrates an exemplary uveal sclera pump.

FIG. 18D illustrates an image showing features of an exemplary patient'seye, in accordance with some embodiments of the subject disclosure.

DETAILED DESCRIPTION

Macular degeneration generally destroys central vision in an afflictedindividual, causing inability to read, drive and conduct an independentand productive life. The rapid decline of vision is generally associatedwith the exudative “or wet” form of the disease in which there is aleakage of fluid from newly formed pathologic choroidal vessels throughthe biologic barrier established by the retinal pigment epithelium. Theleak through the retinal pigment epithelium leads to the destruction ofphotoreceptors with alteration in the structure of the retinal pigmentepithelium into a fibrotic scar or an atrophic state with associatedphotoreceptor destruction.

Current treatments for macular degeneration involve intra-ocularinjections of protein-based antibodies (monoclonal antibodies) tovascular endothelial growth factors (VEGF and related targets) resultingin diminished leakage from neovascularization and recession of the newvessel growth with restoration of the vital interface between the neuroretinal photoreceptors and the retinal pigment epithelium. These currenttherapies require intra-ocular injections due to the short half-life andmolecular size of the existing agents. Intra-ocular injections practicedin the field of Ophthalmology carry many risks, including damage tointra-ocular contents (lens, retina, choroid and potential forintra-ocular infections).

In contrast to previous therapeutic approaches for macular degenerationtreatment, a novel method of treating, preventing, slowing progression,mitigating, and/or reversing macular degeneration is disclosed. In thedisclosed methods, botulinum toxin (in any known form, for example,botulinum neurotoxin or a fragment thereof) or one or more of itspeptide fragments or neurotoxin associated proteins (accessory proteins)are injected intro intra ocular regions (i.e., the globe of the eye)and/or extra ocular regions (i.e., outside the globe of the eye, forexample, the eyelid) of the patient. Application of the disclosedcompounds to one or more extra ocular regions of the patient can treator, in some cases, present visual loss from macular degeneration or anyof its associated conditions. As described herein in detail, botulinumtoxin and fragments thereof may undergo axoplasmic transport.Accordingly, providing botulinum toxin and related compounds to apatient's per-ocular region or extra orbital region(s) can allow for aunique route of penetration into intra-ocular regions and penetrationinto choroid, neuro-retina, and/or retinal pigment epithelium, withoutdirect injection into the eye, avoiding associated complications such asdiplopia and surgical damage associated with intra-ocular delivery. Inthe disclosed remote administration format, botulinum toxin and relatedcompounds may produce barrier-enhancing effects and regression ofpathologic processes associated with macular degeneration, all withoutpotential complications associated with intra-ocular injection.

As used herein, the term “botulinum toxin” refers to any known from ofbotulinum toxin, including but not necessarily limited to: purebotulinum neurotoxin, a fragment thereof, and/or neurotoxin associatedproteins. For example, the botulinum toxin may be produced by thebacterium Clostridium botulinum (for example, by fermentation) or byrecombinant techniques, including engineered variants and fusionproteins. In some particular example embodiments, the botulinum toxin isproduced using recombinant or synthetic chemical techniques (forexample, a recombinant peptide, a fusion protein, and/or a hybridneurotoxin prepared from subunits of different botulinum toxinserotypes). The botulinum toxin may be of serotype A-H and, in someembodiments, the botulinum toxin is present as an isolated botulinumneurotoxin molecule (e.g., botulinum toxin type A neurotoxin having amolecular formula of C₆₇₆₀H₁₀₄₄₇N₁₇₄₃O₂₀₁₀S₃₂ and an atomic mass of 150kDa). The formulation Xeomin® (incobotulinumtoxinA), is an example of apure botulinum neurotoxin (devoid of associated accessory proteins). Inembodiments with an isolated botulinum neurotoxin molecule, one or moreexogenous stabilizers (e.g., albumin) may also be included in theformulation. In embodiments with botulinum toxin in a complexed form(i.e., with hemagglutinin and associated proteins present), one or moreexogeneous stabilizers may also be present. In some particular exampleembodiments, the botulinum toxin used in the disclosed formulations andmethods includes one or more associated proteins that are devoid of pureneurotoxin. Some example associated proteins that are devoid of pureneurotoxin include but are not limited to hemagglutinin derived from thefermentation processes which create the raw materials for botulinumtoxin-based pharmaceuticals (e.g., Hall strain fermentation forbotulinum toxin type A) and non-hemagglutinin, non-neurotoxin from thefermentation of the same process. Additionally, hemagglutinin andfragments thereof which carry specific activity on cell to cell adhesionproteins (e.g., cadherin or other associated proteins) can be separatedor genetically expressed in suitable carriers which subsequentpurification. Fermentation processes prototypes have been described(e.g., Borodic G E, Pearce L B, Johnson E, Schantz E: Clinical andScientific Aspects of Therapeutic Botulinum Toxin Administrations,Ophthalmology Clinics of N America, September, Vol. 4, No. 3, 1991). Insome embodiments, purification of end products of fermentation maycreate the raw materials for the associated proteins. Proteins can berecombinant process expressed from whole or portions of identified genescorresponding to associated proteins.

In some embodiments, the disclosed formulations may include a botulinumtoxin (in pure neurotoxin form or with neurotoxin associated proteinspresent), hemagglutinin (in any known and suitable form), and/or one ormore anti-VEGF agents. In some embodiments, the botulinum toxin may befused to the anti-VEGF agent(s) present, while, in other embodiments,the botulinum toxin may be separate and distinct from (i.e., not fusedto) the anti-VEGF agent(s). As demonstrated in example experiments andembodiments described herein, botulinum toxin has been proven toincrease potency of existing anti-VEGF agents.

Fusion proteins are produced using genetic material corresponding to aprotein or protein fragment, wherein the genes from one protein areligated (via suitable ligases) to one or more separated genescorresponding to other proteins created a protein hybrid withpreservation of the desired biologic activity of each protein to createa useful agent or drug. The fused genetic material may be amplified byPCR in the process, often with addition of connecting materials andelimination of termination codons. In some embodiments, target domainsof botulinum toxin can involve selective nerve uptake (near carboxyterminus of the botulinum heavy chain, fragment of botulinum molecule,or accessory molecules), which express proteins involved in forming orregulating expression of structural proteins connecting cells orregulating cytoskeleton, or involved in proteins governing RPE function,or rod con function. Further, proteins with anti-VEGF activity can befused with botulinum toxin or its fragments or accessory proteins orfragments. Further monoclonal antibodies targeting inflammatorymediators such as complement or other inflammatory autacoids can beadded to a fusion protein, which contains a botulinum fragment. Rhoand/or ROCK modulators may also be added to the fusion protein, in someembodiments. One or more fragments of VEGF receptors, entire receptors,fragments of nerve growth proteins, VEGF subtypes or fragments whichimpede angiogenesis, and/or immunoglobulin fractions which improveprotein stability and decrease immunogenicity may also be added, in someembodiments.

A unique aspect of fusion proteins relates to fluorescent tags, whichcan be used to study transport in animal models (and possiblyclinically) to further understand axoplasmic flow dynamics to targetspecific retinal and choroidal tissues from injection outside the globeand penetrating through various structures such as peripheral nerves. Inthis disclosure, fusion proteins may be formed with botulinumtoxin-based carriers, which affect binding and transport throughperipheral nerves. The fusion protein may contain both the carrierportions of a botulinum subtype, a fragment of a botulinum type, and afluorescent marker, in some embodiments. Other additions with biologiceffects can be added to the fusion protein. Such compositions can beused to study the pharmacodynamic effect of botulinum toxin-basedpharmaceuticals in vivo using standard photography used in ophthalmicpractice (e.g., fluorescein angiography). In some such embodiments, thetag can also confirm that adequate drug has been delivered to thelesions on the retina or choroid targeted for treatment. Differentialpenetration to targeted lesions by the therapeutic agent may alsoprovide important individualized dosing, general dosing, effectivenessof carrier proteins, formulations, and pre-clinical data necessary forqualifying a fusion protein for clinical use. The disclosed methods mayalso involve direct visualization of retinal tissue in vivo or in vitrofor penetration and localization in the retina and choroid.

In these and other embodiments, the disclosed formulations may alsoinclude a stabilizing excipient, such as albumin. In embodiments whereone or more accessory proteins (i.e., complexing proteins, such ashemagglutinin) are present, the concentration and/or activity of theaccessory proteins may be increased from naturally-occurring levels.Numerous configurations and variations will be apparent to those skilledin the art upon consideration of the subject disclosure and teachingsprovided herein.

Current Macular Degeneration Treatment Methods

Currently, effective therapy for age-related macular degeneration (AMD)is limited to the wet form treated with anti-vascular endothelial growthfactors (“anti-VEGF”) agents and related fusion proteins with bothantibody and receptor. The primary treatment for “wet AMD” isintravitreal injection with VEGF inhibitors. Currently, ranibizumab(Lucentis®) has FDA approval, whereas bevacizumab (Avastin) is used onan off-label basis. Eylea® (aflibercept) has been recently approved formacular degeneration with a slightly improved duration of action. Eachof these drugs are given by intra-ocular injection. Eylea®, the newestFDA approved agents, achieves a commercial sale of almost 1 billiondollars per quarter.

Macular degeneration occurs in stages, typically starting with visiblealterations of the retinal pigment epithelium on direct observationusing photographs made through the human pupil and disruption of thecellular organization of the retinal pigment epithelium on opticcoherent tomography (OCT). FIGS. 1A-1C provide illustrations of thevarious stages of macular degeneration, with FIG. 1A illustrating anormal macula, FIG. 1B illustrating dry macular degeneration, and FIG.1C illustrating wet macular degeneration.

FIG. 1D is an image obtained using OCT, illustrating breakage incontinuity of the retinal pigment epithelium, as would occur inearly-stage AMD (age related macular degeneration). Disconnection anddisruption of the retinal pigment epithelial cells can lead to tectonicbarrier defects within the retinal pigment epithelial sheets andbasement membrane (Bruch's membrane) and growth of new blood vesselsfrom the choroid layer of the posterior human eye. During AMD, retinalpigment epithelial cells are often seen breaking away from contiguousand adjacent cells adapting a migration into the neuro-retina (as shownin FIG. 1D). Discontinuity of the integrity of the retinal pigmentepithelium is an important component in the pathogenesis of the disease.In stage 1 of the disease, atrophy, migration, autolysis, anddisorganization occur in cells and associated pigment, leading to anabnormal appearance of the macular with irregularity of the pigmentcharacterized by disruption in the usual pigment densities surroundingthe fovea and irregular cell shapes, often with breakage of retinalepithelial barriers as the disease progresses. Alterations of theretinal pigment epithelium (RPE) leads to the formation of drusens (anddrusenoid) pseudo drusens, pigment clumping, speckling, vitelliformregions, and hypopigmentation. In some cases, these symptoms may appearbefore more devastating changes occur (for example, geographic atrophy,choroidal neovascularization, and sub-retinal hemorrhaging). Methods ofincreasing the blood flow to the choroid are also disclosed herein. Thedisclosed methods may, in addition to other advantages, increase theuveal scleral pumping mechanism, causing a suction effect on the RPE,and allowing for maintenance of linear and planar integrity of the RPE.The disclosed methods of administering botulinum neurotoxin may alsoincrease efficacy of removal of molecular metabolites, which are toxicto cellular function.

As the disruption in cell to cell adhesion and cell to basement membraneadhesion advances, the growth of new vessels from the choriocapillaristhrough the pigment epithelial defects leads to further, more dramatic,vascular and choroidal leakage, disruption of the neural-retinal andretinal pigment epithelium apposition, ultimately resulting indevastating destruction of the photoreceptors (rods and cons) with lossof vision characterized by a central blind spot and loss of a person'sability to read.

FIG. 2 illustrates a dense disciform fibrotic scar with geographicatrophy (GA) in end stage macular degeneration. The eye shown in FIG. 2is beyond legally blind. The disciform fibrotic scar shown in FIG. 2 islikely formed by collagen and related polarization of filamentousprotein from other cellular elements. The retinal pigment epithelium(RPE) shown in FIG. 2 has undergone metaplasia to fibrous scarring (aprocess involving epithelial to mesenchymal transformation) and flatcellular atrophy and degeneration. This is an irreversible (end-stage)form of macular degeneration and difficult to treat.

FIG. 3 is an image obtained using OCT techniques and illustrates leakageof fluid through the RPE under the neuro retina in a case of wet maculardegeneration. The type of leakage illustrated in FIG. 3 is generallyassociated with rapid vision deterioration and requires immediatemedical intervention. Wet macular degeneration (as shown in FIG. 3) canbe treated using drugs such as Avastin®, Lucentis®, EYLEA®, and abicipar(Allergan). These current drugs include different antibodies to variousisoforms of vascular endothelial growth factors (VEGF), which causerecession of the developing neovascularization and/or leakage, resultingin return or stabilization of vision with partial restoration of thestructural derangement in the retina with reduction in sub-retinalfluid.

Treatment with these drugs (anti-VEGF agents) usually require multipleinjections and carry the risk of intra-ocular hemorrhage, infections(e.g., eye threatening endophthalmitis), PVR (post-operativeproliferative vitreoretinopathy), lens dislocation, cataract, glaucoma,and/or retinal break and detachments. These injections can also bepainful. The more injections that are given to a patient, the higher thechance of an administration-related complication. Injections into theeye are more painful than soft tissues surrounding the eye (e.g., lid,orbit, periocular and/or orbital muscles). Experts in the field ofmonoclonal antibodies and genetically engineered proteins have tried toprolong the duration of anti-VEGF agent action using a fusion proteinbetween an anti-VEGF antibody, fractions of VEGF receptor 1 and 2, andFc portion of immunoglobulin.

Overview of Presently Disclosed Treatment Approach

Without wishing to be bound by theory, enhancing the duration andpotency of anti-VEGF therapy using an agent with a very long duration ofaction such as botulinum toxins, may add to both safety and toimprovement in the targeted relief of leakage, neo vascularization ortectonic instability of the continuity of the retinal pigmentepithelium. Extra-ocular botulinum toxin can be used repeatedly, withwell-defined, superior safety results. Extra ocular botulinum injectionsmay, in some cases, eliminate the risk of intra-ocular hemorrhage,infections (endophthalmitis), lens dislocation, cataract, and/or retinalbreak and detachments which can occur with existing therapeuticstandard.

Fewer injections over longer intervals would be an improvement overexisting therapeutic approaches. Many complications of the currentlyknown treatments for macular degeneration are related to the anti-VEGFintra-ocular injection procedure rather than a medicinal side effect ofthe agent. Botulinum toxins work for a longer period than known agentscurrently used for this condition. Further, diminished injectionfrequency would provide safer and more convenient treatment methods forpatients.

In some embodiments, botulinum toxin can be used in conjunction withVEGF antibodies to further enhance potency of the injectable. Forexample, in some cases, treatment of macular degeneration can beaccomplished with one or more applications. Additionally, the disclosedbotulinum toxin-based compounds may reduce or eliminate the need forfrequent intra-ocular injections. Furthermore, botulinum toxin can beused with other agents that promote actin polymerization, such as nervegrowth factor. Botulinum toxin may, in some cases, influence and bind tocadherin proteins, catenin polymers and on the Rac 1 system of acting onintracellular and extracellular actin with enhancement of barrierfunctions along an epithelial or endothelial surface. Botulinum toxinalso can be transported by axoplasmic flow, a unique property thatallows transport into the eye without causing paralytic neuromusculareffects on extra-ocular muscles. As direct diffusion of botulinumtoxin-based compounds may cause paralysis of extra-ocular muscles, theaxoplasmic route of entry provides a novel delivery method forintra-ocular disease and may be used for any of the disclosed compounds.In embodiments where an axoplasmic route of delivery is employed,medication may be delivered through nerves entering the back of the eye(posterior delivery) rather than the front of the eye (intravitreal,drop-topical, or intra-cameral delivery). This is a surprisingimprovement, which advantageously avoids vision-destroying diplopia

Fragments of botulinum toxin also can, in some embodiments, be fusedwith anti-VEGF agents to provide an intra-ocular administration viaaxoplasmic flow, thereby avoiding the need for intra-ocular injectionseven for these agents which must currently be used by riskierintra-ocular injections. Botulinum toxin may interact with mast cellleading to alterations in maintenance neurotransmitters, neuropeptides,trophic agents, nerve growth factors, important to maintain a healthyretinal pigment epithelium. Other mechanisms of action are also possibleand contemplated.

Anatomy of the RPE and its Impact on Macular Degeneration

The RPE is a neuro-derived structure in utero which forms a cellularsheet with cell structure taking the configuration of a regular (equalsided hexagon) in RPE-RPE cell to cell contact. The apical surface is inthe form of a microvilli which maximizes the physical contact withphotoreceptors (rods, cones), allowing the physiologic phagocytosis ofthe photoreceptor membranes while the base of the RPE is attachedtightly to its basement membranes (Bruch's membrane). This anatomicarrangement has been geometrically proven to maximize the compactness ofthe cells minimizing the connection of the cell surfaces. Thisassessment is also the same arrangement for a honey bee hive, andsubject to a proposition made over 2.00 years ago (36 BC) by Romanscholar Marus Terentius Varro (the Honey bee conjecture). Geometricproof followed by Thomas Hales in 1999 (University of Michigan). Thisconjecture proposed that the regular hexagon sheet minimized connectionmaterial while maximizing sheet area. This anatomic allows bees toeconomize on producing beeswax in constructing the hive. Thisarrangement indicated the functional barrier is important for RPE cellsand the biology of maintaining this barrier effect is a vital target foruse of botulinum toxin to treat macular disease. FIGS. 4A-4C illustratethe hexagonal structure of the RPE. In particular, FIG. 4A illustrateshealthy RPE and FIG. 4B illustrates interlocking hexagon structures. Inthe RPE, the structure allows for an economy for actin production, oneof the major intracellular protein governing the attachments of the cellto cell adhesion, and the structural protein forming the submembranesupport for the hexagon. Further, the microvilli of the RPE surface alsois supported in structure by the projection and maintenance ofintracellular actin, as well as the RPE attachment of the basementmembranes. Actin also attaches to other cell to cell protein such ascadherins which functions as the grout-glue of the RPE sheet and supportits functioning barrier effect. Derangement in actin formation,formation of altered forms and arrangement of actin and associatedproteins, and regression of microvilli have been described as earlychanges in stage 1 age related macular degeneration and relateddiseases. FIG. 4C illustrates an RPE suffering from maculardegeneration. As illustrated in FIG. 4C, the actin and microvilli of thediseased cells are misshapen and no longer arranged as orderly hexagons.

Without wishing to be bound by theory, botulinum toxin type A may act asa stimulator of actin on neural tissue. In other words, botulinum toxinmay have an effect on neurally-derived RPE, providing a uniqueopportunity to alter RPE cells in certain disease states, such asage-related macular degeneration. In some cases, cell-to-cell barrierfunction, enhancement of microvilli surface area, and perhaps otherassociate structural proteins may provide a method to maintain RPEstructure and function. In some embodiments, botulinum toxin may retardthe progression of the various stages of macular degeneration andrelated retinal diseases. Increased blood flow to the choroid canincrease the removal of toxic metabolites. In some embodiments, thetoxic metabolites removed from the choroid cause or increasesuction-related pressure change in the choroid, resulting in detrimentalchanges in genomic expression, RPE alignment, as well as reduction inEMT and RPE barrier function. The disclosed methods also favorably slowprogression of dry macular degeneration and reduce conversion of drymacular degeneration to exudative (wet) macular degeneration. Thegenomics expression toward actin may function to keep RPE cells in thedifferentiated state, allow adhesion, and prevent separation fromsurrounding cells and attachment to its basement membrane. It isconceivable that the genomic effects also keep the RPE cell producingother adhesion proteins (and functionally-related proteins) expressed.Repression mRNA expression of proteins of the RPE cell, which governmotility, cell death, cell atrophy, or metaplasia to a fibrocyte mayalso be possible and could be used to treat various stages of maculardegeneration. This effect can be operational, in part with othermechanisms, but structural changes are critical to RPE, a layer derivedfrom neural tubes, with attendant neural elements. The neural elementsof the RPE may allow this useful interaction with botulinumneurotoxin(s) that allow and/or promote a therapeutic response.

Overview of Therapeutic Compounds and Related Methods

In some embodiments of the subject disclosure, a therapeutic formulationis provided. For example, in some embodiments, the therapeuticformulation comprises botulinum toxin (e.g., botulinum toxin types A-G,specifically, C2, C3 and/or various subtypes of A (for example, A1-A5)).The botulinum toxin included in the disclosed therapeutic formulationmay be prepared with standardization of biologic activity via dose usingLD 50, enzyme cleavage of SNAP-25, time to death assays, neuronal cellbased assays, or any other method of measuring biologic activity toproduce suitable dosings. Any fusion protein added to a fragment or anative structure of the botulinum toxin which enhances potency can alsobe used in the disclosed formulations. The disclosed formulations mayalso include permeation adjuvant peptides or other molecules which canenhance diffusion through membranes or potency duration, such aspoly-lysine polymers or albumin, in some embodiments. Suitable adjuvantsmay include but are not limited to: polycationic or poly ionic peptides,hyaluronidase, and/or derivatives of local anesthetics (e.g., lidocaine,Marcaine).

In some embodiments, an injection can be administered through the parsplana so as to avoid retinal tissues, ciliary body or lens. In some suchembodiments, the injected formulation may flow from the injection siteinto the vitreous body. The formulation may then diffuse into the neuroretina and subsequently diffuse into the retinal pigment epithelium. Thetoxin may then be taken up by the retinal pigment epithelium, neovascular membranes, or diffuse through defects in Bruch's membrane,blood retinal barrier, and/or into the choroid. Any suitable level ofactivity may be utilized in some such methods. The retinal pigmentepithelium has an extremely active in membrane vesicular cellular uptakeinteracting with the rods and cones of the neurologic retina and could,in some cases, easily incorporate the molecular botulinum toxin into itscytoplasm. Alternatively, the botulinum toxin may be given in upstreamneural structures (for example, the peripheral nervous system) whicheventually penetrate the inner eyeball via axoplasmic flow.

In cases where the disclosed formulations are injected, one or more ofthe following results may be achieved: (1) leakage from new vesselformation with fluid egression under the neuro-retina or retinal pigmentepithelium may be decreased; (2) regression of new blood vessel growthmay occur; (3) the retinal pigment epithelium degeneration may regress,resulting in intracellular morphologic changes, including reduction ofretinal pigment epithelium activation; (4) cellular element polarity ofthe retinal pigment epithelium may be preserved, with enhancement of itsbarrier function and metabolic activity with enhancing density, length,and expression of microvilli; (5) enhancement of the tight junctionswithin the retinal pigment epithelium and enhancement of pigmentepithelial attachment to its basement membrane may occur; and (6)enhancement and increased choroidal blood flow in the choriocapillarisand under the fovea and perifoveal regions.

In some cases, injection results may be measured using one or more ofthe following: (1) visual acuity and/or validating methods of measuringacuity; (2) contrast sensitivity; (3) fundus photography; (4)fluorescein angiography (including OCT angiography with variousorientations for assessment of choroidal perfusion); (5) OCT (forexample, examining sub retinal fluid, neovascularization under andthrough the retinal pigment epithelium, of any physical type); (6)changes in the RPE (drusen/drusenoid heights and volumes, density,distance from basement membrane, migration, loss of photoreceptors, lossof IS-OS and outer nuclear lines, fluid accumulations in retina andsubretina, pseudo drusen density, pigment clumping and tears, choroidalthickness, neuro-retinal thickness, RPE atrophy, formation and leakagepattern of choroidal neovascularization, extent of geographic atrophy,hemorrhage, and shape and regularity of lines of retina defined by OCT(for example, ONL, IS-OS, RPE alignment; (7) Amsler grid; (8) autoflorescence from RPE lipofusen; (9) focal ERG (electro-retinogram); (10)polarity, thickness and shape changes in the retinal pigment epitheliumusing OCT; (11) visual fields; (12) any subjective instrument whichassesses patient satisfaction that has been validated against objectivemeasurements; and (13) use of conventional clinical study methods usingcontrols and repeated injections. In some cases, serial follow-ups maybe made with the patient and assessments of the need for repeatedinjections may also be utilized, as needed. In these and otherembodiments, fundus photography and OCT may be used for monitoringtreatment effect. The OCT-A is particularly useful for assessingimprovement in choroidal blood flow in critical areas of the macula(e.g., in the choriocapillaris). Specifically, OCT-A techniques can beeffectively used to evaluate retarding and/or prevention of developmentof dry macular degeneration using the disclosed methods. OCT-A withstandard OCT can detect beneficial effects of botulinum toxin on defectsin the Bruch's membrane (e.g., breaches in the Bruch's membrane), fluidin sub retinal space, and/or linear RPE organization and integrity.Laser Doppler techniques can also be used to assess choroidal bloodflow, if desired. As used herein, the term “choroidal blood flow”includes, relates to, and/or refers to blood flow in thechoriocapillaris.

Effects of Botulinum Toxin on Intra Cellular Cytoskeleton

Botulinum toxin may have important biologic effects on endothelium andRPE, which plays an important role in the pathogenesis of degenerativeand exudative forms of human retinal disease. The RPE has been studiedusing electron microscopy during early stages and later stages of agerelated macular degeneration. Studies have revealed condensations ofintracellular cytoskeleton near the basement membrane (base) of thecells causing disruption of the cell membrane, with cell shapeirregularity, loss of polarity, disruption in cell to cell adhesion,accumulation of leaked protein with membrane instability, andderangements of the apical-apical orientation of the RPE cells with therods and cone cellular structure. A distortion of the RPE can result inone or more of the following: (1) inability of the RPE to sustain itssupportive functional and metabolic interplay with macular rods andcones, maintain the tight barrier between the choroid and neuro-retinaallowing for emission of reactive macromolecules from the neuro-retinainto the choroid. Such exposure excites release of vascular growthfactures as well as mediators from choroidal endothelial cells, nerves,mast cells leading to fluid accumulation under the neuro retina (RPE andneurosensory detachment, hall mark of both “wet” and “dry” maculardegeneration); (2) leakage from the neo-vascular endothelial tightjunctions which occurs because of a deranged cytoskeleton associatedwith endothelial vasculature; (3) exposure of the antigenic structure ofthe neuro retina through the blood retinal barrier, causing reactivityof immune cells in the choroid with a limited response from bloodcontaining cellular elements which circulate through the choroid. Theimmune response can include complement activation, which further damagesRPE structure; (4) interruption of the rates of nutrient delivery intothe neuro retina leading to toxicity of the rod and cones and RPE; (5)loss of RPE micro-villi, critical for maintaining rod and cone functionby removal of photoreceptor breakdown products; (6) destruction of rodsand cones; and (7) formation of a geographic atrophic state of RPE.

FIGS. 5A-5F show images of RPE obtained using microscopy techniques. Inparticular, FIGS. 5A-5F illustrate disruption of membranes, sub membranecondensation, alteration of hexagonal shapes of the structure, RPEautolysis, stress fiber formation from actin (shown in FIG. 5A), barrierfunction disruption, and migration of the RPE away from the barriersheet. It should be noted that structure and function relationship ofthe neuro-retina is one of isolation from blood elements with most ofthe exposure being to vitreous body, a chamber containing hyaluronidatewith no transient perfusion. Defects in the retinal vasculature arefairly consistent in creating retinal pathology. The blood retinalbarrier in the retinal and choroidal vascular is important to the healthof the neuro retina. The choroid is one of the most densely perfusedtissues in the human body and the RPE and photoreceptors are highlymetabolically dependent on a close structural relationship with thechoroid. Separation of the blood compartment with both retinal andchoroidal vascular is important in maintaining neuro-retinal health andfunctional integrity of photoreceptors. Further, certain antigenicstimuli get exposed with barrier breakdown which excites geneticallyindividuals to react with immune responses at varying levels includingbut not limited to complement activation, neurogenic reactivity,alteration in regulatory autocoids, alterations in cell functionsindependent of inflammation, fluid accumulations within neuro-retina,barrier incompetence in choroidal and retino vascular endothelium, anddysfunction of the RPE photoreceptor functions.

The disruptions of the cytoskeletons of endothelium and RPE bycytoskeleton structure in endothelium and RPE are important to thepathogenesis of macular degenerations with respect to leakage of bloodcontaining fluid and membrane altering mediators and function of thechoroid of the eye. Generally, increased in generation of pathologicarrangements of actin, microtubule proteins, accumulated as a first stepin macular degeneration associated with distortion of RPE andendothelial membranes, which may cause: (1) toxic leakage of sub retinalfluid (wet macular degeneration); (2) loss of cell to cell adhesion andcell to basement membrane adhesion disruption of barrier function(drusen and drusenoid formation, RPE migration); (3) loss of polarityorientation of RPE, which can be important to its role supporting thestructure and function of the rod and cones (progressive drydegeneration) and may ultimately result in loss and retraction of RPEmicrovilli; (4) loss of RPE ability to remove photoreceptor breakdownproducts (lipofuscin) at a sufficient rate to avoid photoreceptortoxicity (auto florescence increase); (5) pathologic condensation of RPEintra-cellular fiber elements ultimately reflected by metaplasia of theRPE into a white “fibrocystic” cell type which appears on fundusphotography as a “Disciform scar”(see FIG. 2) and formation ofgeographic RPE atrophy and neurosensory retinal atrophy; (6) disciformscars and geographic atrophy are often seen in patients blinded withmacular degeneration reflecting evidence of the nature of thedegenerative and deranged process by which the macular is destroyed byalteration in accumulation orientation of intracellular pathologic actinand related fiber accumulation, which fundamentally alters the RPE andcauses RPE/photoreceptor death. The ensuing result is retinal pigmentepithelial to mesenchymal type differentiation to a fibrocyte, migratedcell, and/or atrophic cell.

The ensuing events involves a substantial change in mRNA expression bythe RPE to reorganized cell attachments, basement membrane attachment,pigment epithelial motility and migration into the neuro-retina. Thisprocess denotes the early changes in macular degeneration with vascularresponse with growth of vessels into the RPE and choroid denoting thelater stages (FIG. 1, stages of macular degeneration). Following barrierfunction disruption, immune process may ensure, which results incomplement activation, mast cell activation, neuropeptides release,which further aggravates disrupted barriers and fluid accumulation;and/or (7) genomic changes resulting in altered RPE morphology, retinallayer tissue dysfunction and loss of photoreceptors.

It should be noted that botulinum toxin can get into cells either viaspecialized receptors as exists on nerves cells or by facilitation withadjuvant proteins either in vivo or in drug formulation. Vitalconcentrations may, in some cases, be inherently low with thismolecule's ability to effect enormous changes in cytoplasmic physiologyor genomic responses and exquisitely low molecular concentrations.

Botulinum and Cytoskeleton Interactions

The disclosed formulations and methods, in some embodiment, involveinjections or topical application of a botulinum toxin formulation forthe treatment of macular degeneration and other relational degeneration.Botulinum toxin A may have a critical effect on cytoskeleton structures.The C3 version has been noted to interact of the Rho actinpolymerization system in cellular biologic experimental observations.While the C2 and C3 toxins may not cause neuromuscular weakness, theseagents are cyto toxins able to cause cell death by different mechanismsthan type A subtypes, B, C1, D, E, F, and G. Further, as described indetail below, animal injection of type A botulinum into muscle cells maycause a shrinkage of cells associated with diameter morphometric out ofproportion to the effect created by nerve cutting (neurogenic atrophy).This rapid rate observation (which was not previously reported)indicates that the A toxin has a fundamental direct effect on thecytoskeleton of muscle cells independent of neuromuscular blockageassociated with blocked acetyl choline release on myoneural junctions.This effect may cause a dissolution and re-organization of cytoskeletonactin and related intracellular micro tubules to an extent that theeffect can interfere with a degenerative process leading to cell death,critical dysfunction, and block a critical disease degenerating processso as to preserve cell function. Caspase and apoptotic intracytoplasmicenzymes can be depressed, in some cases. The effect would be to maintainpolarity of vital cell structures such as the RPE, delay or halt theaccumulation of pathological cytoskeleton proteins, with preservation ofcell structure polarity and associated cell interacting functionallywith the target cell group.

In some embodiments, endothelial cell health can be preserved as well asintegrity of any cell undergoing a degenerative process by increases inthe intracellular generation of cytoskeleton protein which disfigure theshape or critical cell configuration destroying critical junctions andassociated barriers, movement of metabolites, neuro-retinal antigenicexposure, or cell to cell relations. Such changes can be elicited byalterations in expression of cellular adhesion proteins, interactionswith vital surface and internal receptors governing cell metaplasia,apoptosis, epithelial mesenchymal transformations, epithelial sheetloosening and adhesiveness to basement membranes, alterations in thequantity of various isoforms of adhesion proteins such as cadherinisoforms and related proteins so as to alter barrier functions ofepithelium and endothelium to inflammatory cytokines (such as VEGF) andrelated proteins. Important barrier functions in macular degenerationinclude endothelial governing leakage, epithelial cell to cell adhesiongoverning RPE barrier, choroidal neo-vascular barrier functions alongthe neo vascular endothelium. Additionally, botulinum toxin can suppressinflammatory autacoids, such as mast cell function.

In the case of the RPE, the tight junctions at the level of the RPE canbecome incompetent from abnormal cytoskeletal protein accumulation,causing barrier fractures along tight junctions with ensuing antigenicexposures of the neuro retina to choroid, with opportunity for variousimmunologic and inflammatory proteins to egress, choroidal fluid, andsubsequent photoreceptor death based on immunologic reactivity. Usingthe disclosed techniques involving the administration of botulinumtoxin, barrier effects can be improved and barrier leakage can bemitigated, due to increased blood flow in regions affecting the macula.Such as process involves histamine release inferentially present inplatelets and mast cells both present in choroid. Vasoactive intestinalpeptide and CGRP may also play a role. Mast cells are capable ofinterplay with autonomic nerves present in choroid and still anothertarget for botulinum modulating or blocking effect. Barrier functionseems to be implicit and tissue organization of the retina and choroidand disruption of this function may be viewed as upstream derangement,occurring in macular degeneration. It is noted that retrograde movement(toward the central nervous system) and ante grade movement (away fromthe central nervous system) of botulinum toxin via peripheral nerves orveins occurs during use of the disclosed compositions and methods.Further, direct penetration of the disclosed formulations into the eyemay encounter natural barriers of scleral and cornea. Prior to thefiling of the subject application, botulinum toxin has not beenadvocated for intraocular diseases. This is due, at least in part, tothe fact that the eye barrier was previously believed to block theneurotoxin from entering the eye.

Interaction of the RPE and Photoreceptors

The phagocytic interaction of the RPE on the rods and cones is criticalfor photoreceptors health. Damage to this interplay will result inphotoreceptor damage and eventual death with vision loss. Driving thisrelationship at the sub cellular level is the microtubules within theretinal pigment epithelium which allows for phagocytic interactions at arapid cellular rate, with active actin and related tubulepolymerizations allowing for photoreceptor maintenance. Defects incytoskeleton assembly maintenance and disassembly can result inphotoreceptor damage.

Such defects can be reflected in the disorganization of the polarity ofthe RPE cells as well as alterations in cell shape actin and tightjunction integrity and cellular relationships on the basement membrane(Bruch's membrane). Early macular degeneration changes are associatedwith alterations in RPE morphology and accumulation of denseaccumulation of subcellular fibers indicating microfiber dysfunction(Drusen body accumulation). Auto fluorescence is a sign of RPEdysfunction, indicating a compromised RPE with accumulation of Rhodopsindue to defective catabolism and accumulation of lipofuscin pigment seenwith blue light filters on retinal cameras. Lipofuscin is an indicationof functional RPE dysfunction and often occurs in both wet maculardegeneration and in progressive dry macular degeneration with geographicatrophy. Increasing removal of lipofuscin and various other metabolitesdue to an increase in the blood flow-driven uvea scleral pump is usefulin improving the outcome of stages of macular degeneration characterizedby RPE-pumping dysfunctions.

Botulinum Toxin and Microtubule Derangements and Microfiber Accumulation

Botulinum toxin has the ability to alter the accumulation formation ofsubcellular actin and microfibers so as to suppress the pathologicaccumulation polymerization of critical cytoskeleton components toprovide one or more of the following:

-   -   1. Maintain barriers within the RPE essential for maintaining        integrity of the neuro-retina and rods and cones maintained by        tight junctions.    -   2. Maintain polarization and cytoskeleton to assure continued        function.    -   3. Maintain integrity of endothelium and suppress        neovascularization from the choroid    -   4. Block or modulate mast cell activity and modulate release of        neuropeptides or other mediators in the choroid which can damage        or sustain photoreceptors.    -   5. Microvilli enlargement and enhancements.    -   6. Barrier function within the basement membrane attachments of        the RPE and cell to cell adhesions of the RPE.    -   7. Block exudative vascular leakage from choroid.    -   8. Improving choroidal blood flow by increasing the pumping        mechanism of the choroid and pressure effects on the RPE.        Botulinum Interplay with Microvilli of the Retinal Pigment        Epithelium

The retinal pigment epithelium contains microvilli, a critical structuremaintaining the physiologic health of the rod and cones of theneuro-retina. The neuro-retina structures convert images and light intotransmittable signal into brain via optic nerve projections allowing forvisual decoding within the central nervous system. The effect of age isto dwindle the extent, size and integrity of the microvilli causing adysfunctional microanatomy between the rods and the cone ultimatelyleading to the early stages of macular degeneration. The effect ofbotulinum toxin causes a shift in this deterioration, expression ofenhance actin and associated protein polymerization, with rejuvenationand reversal of vital structures of the apex of the retinal pigmentepithelium causing cessation of the degeneration and deterioration ofthe maintenance role of the choroid and retinal pigment epithelium onthe neuro-retina.

Botulinum toxin species effects this change act on Rho kinase and ROCKintracellular systems achieving the shift in expression of mRNA towardvital protein expression causing a robust microvilli and reversing orimpeding atrophic shift and apoptosis of RPE cells involved in maculardegeneration. In genomic studies using neural ganglion with assessmentusing robust cDNA fragments on gene chips, botulinum toxin has eliciteda mRNA response which regulates production of proteins important toactin expression, cell to cell adhesion molecules and anabolic proteinsgoverning enhance cell structures. Photoreceptor proteins have beenshown to shift expression after botulinum toxin infusions into cellcultures.

Duration of Action

The disclosed formulations and methods may provide a biologic effectwhich enhances duration of action over existing therapies, with possibleeffects lasting between 4-50 weeks and possibly longer upon repeatedinjections. The increased duration may allow for fewer invasiveprocedures needed to administer the drug when intra-ocular injectionsare used. Botulinum toxins have varying durations in clinical practicedependent on the target tissue. The autonomic nerve effects can lastlonger than the effect on heavily myelinated motor nerves. Most of thenerves within the choroid have minimal myelination and many representautonomic nerves from ganglionic structure outside the orbit andaccessible to injection with a botulinum formulation described herein.Accessing the macular eye without orbital injection, high dose surfaceapplications, intra-ocular implant or injection procedures, but insteadthrough extra-orbital and para orbital injections, is an advantageousfeature of the presently disclosed methods. Additionally, the presentlydisclosed methods can also limit neuromuscular paralysis of theextra-ocular muscles, which can cause vision-destroying diplopia and/orptosis.

The duration of action of anti-VEGF agents (both FDA approved and indevelopment) have targeted longer duration of action as the need forintra-ocular injection is associated with many complications. Fewerinjections or a period of time is more comfortable for a patient andreduces administration risks. The half-life of the aflibercept EYLEA® inrabbit is about 7 days. In contrast, 0.5 mg of ranibizumab (Lucentis®)is about 2.88 days and 1.25 mg of bevacizumab (Avastin®) is 4.3 days.

Given botulinum toxin-based pharmaceuticals have intrinsically longduration of action, fewer injections may be needed as compared to knownanti-VEGF agents. Further, botulinum toxin can increase the efficacy andduration of action of existing anti-VEGF therapies, allowing for fewerinvasive intra-ocular injections. This was an unexpected result andindicates a unique and unanticipated effect of botulinum administrationwith paraorbital injections. Further cases have demonstrated increasedduration of action of anti-VEGF agents. Botulinum formulations can alsoact on regulators targeted by anti-VEFG receptors, including variousforms of tyrosine kinase enzyme pathways, which suppress VEGF activitymembrane permeability, cell transformation and migration, particularlyat the choriocapillaris and retinal pigment epithelium.

This potency enhancement of anti-VEGF agents has been seen in severalexperimental examples provided herein (see, for example, Example 8). Forneuromuscular effect, duration of action is generally between 10-14weeks. With some preparations, duration as long as 20 weeks betweentreatments may be possible. Further, for autonomic effects, durationsfor up to 24 weeks have been recorded. As botulinum technology offerssuperior duration over the currently used and anticipated with anti-VEGFpharmaceuticals, the convenience for patient treatment, with marked riskreduction and the possibility of additive effects are clear advantages.Further anti-VEGF agents have been associated with vaso-occlusivedisease (e.g., stroke and arterial occlusions). Despite complicationswith anti-VEGF agents, assessments with botulinum toxin have notresulted in any serious reported complications at conventional dosinglevels (as defined by FDA-approved dosings). Botulinum toxin-basedpharmaceuticals as described herein can act similar to anti-VEGF agentsand, in some embodiments, can increase potency and duration of ant-VEGFagents (see Example 1).

Dosing

The disclosed therapeutic formulations may, in some embodiments, includebotulinum toxin or a fragment thereof. Any suitable form of botulinumtoxin may be used in the disclosed formulations, for example, thedisclosed formulations may include botulinum toxin A1-A5, B, C1-3, D, E,F, G and H. Additionally, fermentation yields with higher LD 50 unitsper cc of fluid may be used as a source of botulinum toxin, with orwithout complexing proteins. In some embodiments, fragments of botulinumtoxin may include formulations devoid of neuromuscular junctionactivity. As will be understood, formulations devoid of neuromuscularjunction activity may avoid muscle contractility weakness andcomplications caused by paralysis (e.g., diplopia, ptosis, dysphagia,facial paralysis and asymmetry, lagophthalmos, jaw and chewing weakness,and other forms of muscles weakness).

The disclosed formulations can be prepared with an appropriate dose ofbotulinum toxin. For example, in some embodiments, the disclosedformulations may be administered to a patient according to one or moreof the following dosings:

0.01 to 0.5 LD 50 units, administered via intra-ocular, extra ocular,peri orbital, subconjunctival peribulbar injection, epibulbar injection,or topically.

0.5 to 5 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

5-10 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

10-20 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

20-40 LD 50 units, administered via intra-ocular, extra ocular,periorbital, subconjunctival peribulbar injection, epibulbar injection,or topically.

40-80 LD 50 units, administered via intra-ocular, extra ocular,periorbital, subconjunctival peribulbar injection, epibulbar injection,or topically.

80-160 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

160-320 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

320-640 LD 50 units, administered via intra-ocular, extra ocular, periorbital, subconjunctival peribulbar injection, epibulbar injection, ortopically.

640-1280 LD 50 units, administered via intra-ocular, extra ocular,subconjunctival peribulbar injection peri orbital, subconjunctivalperibulbar injection, epibulbar injection, or topically.

0.5-25,000 LD 50 units, administered via intra-ocular, extra ocular,subconjunctival peribulbar injection peri orbital, subconjunctivalperibulbar injection, epibulbar injection, or topically.

0.01 to 3,000 LD 50 units, administered via intra-ocular, extra ocular,subconjunctival peribulbar injection peri orbital, subconjunctivalperibulbar injection, epibulbar injection, or topically.

1280-6,000 LD 50 units, administered via intra-ocular, subconjunctivalperibulbar injection peri orbital, subconjunctival peribulbar injection,epibulbar injection, or topically.

In some example methods, conventional dosing of botulinum toxin may beused. As used herein, the term “conventional dosing” refers to anyFDA-approved dosing of botulinum toxin for an indication of the head orneck. In select embodiments, 300 LD 50 units or less of botulinum toxinmay be administered to a patient. For botulinum toxins with lower LD 50potency, conversion assessment and table subject to existing doseconversions may be used. These example doses are given for aconventional form of botulinum toxin marketed using the trademarkBOTOX®.

Conversion Table for other forms (immunotypes, formulations) ofBotulinum Toxin

1. Xeomen:Botox—about 1:1 to 1.5:1.0 (Botox® more potent)

2. Dysport:Botox—about 3:1 to about 7:1 (Botox more potent per unit)

3. Mybloc:Botox about 50:1 to about 100:1 (Botox more potent)

Topical and Subconjunctival Administration

As described herein, clinical efficacy can be derived from topicalapplication of botulinum toxin based pharmaceuticals. Dosing can rangefrom 1-2500 Units using the botulinum toxin with complex. In order toreduce unwanted toxicity, the botulinum toxin protein molecule can bemodified so as to reduce or eliminate the neuro-muscle effect so whenapplied to a mucous membrane surface like the ski, conjunctiva, ormucosal surfaces in the sinus nose, or mouth paralytic or weakening sideeffect do not occur. Further adjuvant protein can be removed so as tolimit toxicity from gastro-intestinal absorption by eliminatingbotulinum toxin derived hemagglutinin protein represent as the botulinumtoxin complex (e.g., BOTOX®). As dosing is determined by LD 50 in SwissWebster mouse, units generally are accepted but may be converted intoalternate forms such as derived from alternate assay or quantitativemethod.

Importantly, permeators such as lidocaine, albumin, polylysine, ormechanical devices such as contact lens, intra-ocular implants,subconjunctival implants, can be used to provide a delivery systemappropriate for intra-ocular administration. Transconjunctivaladministration through lid or bulbar conjunctiva can be used. Dryingtechniques of the ocular surface can also be used to enhancepenetration. Use of goggles which enhance permeation of the ocularsurface can be employed to provide a positive pressure atmosphere orhyperbaric state such as used in hyperbaric oxygen chambers. Micropunctures of corneal and conjunctival epithelial followed by botulinumtoxin based protein with or without contact lenses can increase cornealand ocular penetration. Varying concentration allowing for moreeffective uptake of the internal eye can be employed based on thespecific stage of macular degeneration and based on specific pathologicfindings clinically or SD-OCT.

It should be noted that subconjunctival injections, although notintra-ocular, place botulinum toxin next to extra-ocular muscles. If aneuro paralyzing formulation is used, any dosages above 2-5 (Botox®)units or dosing equivalents may induce the complications of diplopia andptosis.

Intra cameral (aqueous humor) injections are known to be safer thanintravitreal injections and can provide a superior method of increasingintra-ocular botulinum concentrations, with less chance of damage tointra-ocular contents.

It is important to note that, although the present disclosure oftenrefers to methods that include injections of botulinum neurotoxin, inselect embodiments, botulinum neurotoxin and/or preparations containingbotulinum neurotoxin may be administered to a patient using alternativedelivery methods, such as topical application. In select embodimentsthat include topical application, botulinum neurotoxin may beadministered in dosing ranges of at least 20, at least 25, at least 30,or at least 35. Numerous configurations and variations are possible andcontemplated.

Timing and Use of Botulinum Toxin in Conjunction with ConventionalAnti-VEGF Drugs Used to Treatment Macular Degeneration

Wet macular degeneration (as shown in FIG. 3) can be treated using drugssuch as Avastin®, Lucentis®, EYLEA®, and abicipar (Allergan). Thesecurrent drugs include different antibodies to various isoforms ofvascular endothelial growth factors (VEGF), which cause recession of thedeveloping neovascularization and/or leakage, resulting in return orstabilization of vision with partial restoration of the structuralderangement in the retina with reduction in sub-retinal sub RPE, andintra retinal fluid. Botulinum toxin reparation described herein can begiven prior to an intra vitreal anti-VEGF agent, simultaneous in anextraocular (e.g., para orbital or peri orbital type injection), orafter an intravitreal injection. The timing of various treatments may beimportant as intravitreal anti-VEGF type agents and injections have ashort duration of action relative to botulinum toxin preparations. Whilethe onset of activity of a botulinum agent can vary, botulinum toxin canbe placed in an optimal phase relative to activity onset of an anti-VEGFagent to enhance potency. Examples 1 and 8 described below in detaildemonstrate enhanced anti-VEGF potency induced by a botulinum toxinpreparation. As more fully described with respect to Example 8,administration of a botulinum toxin preparation may allow for completeremoval of sub-retinal fluid when given prior to a single administrationof an anti-VEGF agent, such as avastin or afibercept. The data obtaineddemonstrates anti-VEGF potency enhanced by prior or simultaneous use ofbotulinum toxin preparations. Enhancement in anti-VEGF potency can be avaluable improvement in clinical practice in unresponsive patients withwet (exudative) macular edema or any leakage from retinal diseasesdescribed herein. Potency enhancement can be made both with priorapplications or simultaneous application of botulinum toxin usingmethods described herein. Such methods include but are not limited topara orbital injection of botulinum toxin preparations, which pose noside effects of diplopia, ptosis, or any orbital or facial muscleweakness.

Furthermore, potency enhancement of anti-VEGF agents can be advantageousfor many reasons. For example, a longer duration of action of anyanti-VEGF agent (in current use or in future development) will result infewer loading doses of intra-ocular anti-VEGF agents being needed.Reducing the number intra-ocular injections needed can also cause fewerintra-ocular injections of a glucocorticoid or glucocorticoidslow-release implantation device, should a glucocorticoid agent be usedin the macular degeneration treatment. The use of a botulinumtoxin-based agent for the treatment of exudative macular degenerationcan also be helpful for use in “treat and extend” or pro re nata (PRN)treatment regimens.

The disclosed botulinum toxin-based preparations and methods disclosedherein can be used for duration enhancement and potency-enhancingeffects on currently used anti-VEGF agents. The disclosed methods andpreparations can, in some embodiments, improve and reduce the costburden on Federal insurance programs, such as Medicare and Medicaid, aswell as private insurance companies, by reducing the number ofprocedures needed to treat this common cause of blindness. Reduction inintra-ocular injections can also reduce resource costs and, mostimportantly, make the treatment program safer for patients.

In some embodiments, the disclosed methods involve measuring the impactof patient care by frequency of needed injections based on various formsor ocular coherences tomography (OCT), visual testing, fluoresceinangiography of the retina, and fundus photography. Reduction infrequency of intra-ocular injections, particularly using anti-VEGFagents, is a durable measurement for treatment enhancements and can betested against saline controls. Further, duration of an anti-VEGF agentafter loading dose can be a direct measure of benefit against salinecontrols. Reducing the frequency of intravitreal injections and theextent and amplitude of fluid reduction in the macula as well as theduration of effect after a determined loading dose of an anti-VEGF agentis administered by intra-ocular injections can also be used to determineefficacy of the treatment applied. Onset of effect of an anti-VEGF canalso be measured with a botulinum toxin using various forms of OCTmeasurement and compared against suitable controls. Case studiesdescribed herein have indicated longer than expected results in patientswith wet and exudative macular degeneration. Additionally, more rapidresponses to anti-VEGF agents were observed than expected and areduction in intra-ocular anti-VEGF injection over an extended period oftime were also observed.

Drugs in Trials for Dry Non-Exudative and Wet Exudative Stages ofMacular Degeneration

Tables 1 and 2 outline various agents in trials or being contemplatedfor trials for the treatment of dry macular degeneration.

TABLE 1 Summary of Clinical Trials Targeting Macular DegenerationMechanism of Route of Study Clinical Trial Drug/Therapy ActionAdministration Group/Sponsor Number Photoreceptor and RPE preservationTrimetazidine Anti-ischemic agent Oral Institut de Recherches withcytoprotective Internationales Servier effects Alprostadil Increasechoroidal Intravenous UCB Pharma NCT00619229 (prostaglandin E1) bloodflow Moxaverine Nonselective Oral Medical University of NCT00709449phosphodiesterase Vienna NCT01629680 inhibitor NCT00709423 SildenafilPhosphodiesterase Oral Duke University NCT01830790 type-5 inhibitorMC-1101 Increase choroidal Topical MacuCLEAR. Inc. NCT01601483 bloodflow Ozonated Increase oxygenation Autohemotherapy autohemotherapyFenretinide Visual cycle modulator Oral Sirion Therapeutics ACU-4429Oral Acucela Inc. NCT1802866 Tandospirone Neuroprotection Topical AlconResearch NCT00890097 CNTF (NT-501) Intravitreal implant NeurotechNCT0044954 Pharmaceuticals Brimonidine Intravitreal implant AllerganNCT00658619 RN6G Anti-amyloid Intravenous Pfizer NCT01577381 antibodiesGSK933776 Anti-amyloid B Intravenous GlaxoSmithKline NCT01342926antibodies Doxycycline Promotes photoreceptor Oral Paul Yates, MD, PhD.,NCT01782989 (Oracea) survival University of Virginia Prevent oxidativestress injury AREDS formulation Antioxidant Oral National Eye InstituteNCT00345176 Crocetin Reduces apoptosis, Oral increases oxygen diffusionthrough plasma, reduces lipid peroxidation, upregulates trophic factorsCurcumin Reduces lipid Oral peroxidation and formation of reactiveoxygen species, modulating the expression of many oxidative stress-regulating genes, such as PDGF, VEGF, HO1, and others Vitamins B9, 12, 6Decrease serum Oral homocysteine levels Resveratrol Modulates cell Oralproliferation, apoptosis, and angiogenesis Inflammatory SuppressorsEculizumab Humanized monoclonal Intravenous Philip J. Rosenfeld, MD,NCT00935883 (SOLIRIS) antibody targeting Ph.D., University of complement5 Miami ARC-1905 Peylated RNA aptamer Intravitreal OphthotechCorporation NCT00950638 targeting complement 5 injection FCFD4514SHumanized monoclonal Intravitreal Genentech, Inc. NCT01602120(lampalizumab) antibody antigen- injection binding fragment targetingcomplement FD LFG316 Humanized monoclonal Intravitreal NovartisPharmaceuticals NCT01527500 antibody targeting complement 5 Glatrirameracetate T cells and Subcutaneous The New York Eye and NCT00541333(copaxone) inflammatory Ear Infirmary NCT00466076 suppressor FlucinoloneCorticosteroid Intravitreal implant Alimera Sciences NCT00695318acetonide (iluvien) Sirolimus mTOR inhibitor Subconjunctival NationalEye Institute NCT01445548 (rapamycin) Lipid metabolism Statins Loweringlipid Oral accumulation in Bruch's membrane Heparin-induced Reducesserum LDL, Extracorporeal B. Braun Avitum AG NCT01840683 extracorporealfibrinogen, lipoprotein circulation lipoprotein precipitation RPE:Retinal pigment epithelium, LDL: Low-density lipoprotein, CNTF: Ciliaryneurotrophic factor, AREDS: Age-Related Eye Disease Study, PDGF:platelet-derived growth factor, VEGF: Vascular endothelial growthfactor, HO1: Heme-oxygenase-1, FD: Complement factor D

TABLE 2 Summary of Clinical Trials Targeting Geographic Atrophy Clinicaltrial Status of Target Treatment number Company clinical trials Anti-Eculizumab NCT00935883 Alexion Completed inflammatory Pharmaceuticalsphase II (Cheshire, CT) Sirolimus NCT00766649 National Eye InstituteCompleted (Bethesda, MD) phase I/II Lampalizumab NCT02247479Hoffmann-LaRoche Phase III (Basel, Switzerland) currently Roche (Basel,recruiting Switzerland) ARC-1905 NCT00950638 Ophthotech (Princeton, NJ)Completed phase I Glatiramer NCT00541333 The New York Eye & Phase IAcetate Ear Infirmary (New suspended York, NY) participant recruitmentAntioxidants AREDS2 NCT00345176 National Eye Institute Phase III(Bethesda, MD) completed OT-551 NCT00306488 National Eye Institute PhaseII (Bethesda, MD) completed Othera Pharmaceuticals (Exton, PA) Visualcycle Fenretinide NCT00429936 ReVision Therapeutics, Phase II inhibitorsInc. (San Diego, CA) completed Emixustat NCT01802866 Acucela Inc.(Seattle, WA) Phase II/III Hydrochloride ongoing (ACU-4429) ALK-001NCT02230228 Alkeus Phase I Pharmaceuticals, Inc. completed (Boston, MA)Amyloid beta MRZ-99030 NCT01714960 Merz Pharmaceuticals Phase I GmbH(Dessau-Roßlau, completed Germany) RN6G NCT01003691 Pfizer (New York,NY) Phase I completed GSK933776 NCT01342926 GlaxoSmithKline Phase II(Brentford, UK) ongoing Choroidal MC-1101 NCT02127463 MacuCLEAR, Inc.Phase II/III perfusion (Plano, TX) currently recruiting Stem cellMA09-hRPE NCT01344993 Ocata Therapeutics Phase I/II therapy(Marlborough, MA) currently recruiting MA09-hRPE NCT01674829 CHABiotechCO., Ltd Phase I/IIa (Seoul, South Korea) currently recruiting HuCNS-SCNCT01632527 StemCells, Inc. Phase I/II (Newark, CA) ongoing

It is of note that there are no clear agents that consistently work forrepressing or stopping dry macular degeneration. Also of note is thefact that no contemplated treatment agents contemplate a botulinumtoxin-based pharmaceutical for the treatment of dry or wet degeneration.The mechanisms of action are also listed in Tables 1 and 2. Note thatanti-VEFF, choroidal flow enhancers, anti-amyloid antibodies, visualcycle modulators, antioxidants, apoptosis modulators, a number ofanti-complement directed antibodies, neuroprotectors, nerve growthfactor, phosphodiesterase inhibitors, stem cells, and anti-inflammatoryagents are being tried. However, no review or study either contemplatedor provided rationale or reduction to practice of a botulinumtoxin-based pharmaceutical. Most recently, Lampalizaumab (Genetech,Inc.) has been reported to fail at the 2017 American Academy ofOphthalmology in New Orleans. Recently, studies involving insertingintra-ocular implants complexed with corticosteroids for slow releasehave been added to Anti-VEGF agents (e.g., EYLEA®) for wet maculardegeneration treatment. Further, newer agents, such as angiopoietin, arebeing tried with anti-VEGF agents to increase potency and duration ofaction of intravitreal drugs.

At a 2017 Retina meeting, a review of eye delivery mechanisms wasconducted which failed to cite trans neural delivery mechanism for thetreatment of choroidal or retinal diseases, including AMD. The voidgives credence to this novel component to formulations and treatmentmethods described herein (e.g., trans neural delivery of botulinum orits components to the choroid and choroidal ganglion, with favorableeffects on RPE and neuroretina).

Pharmacodynamic Delivery System for the Treatment of Human MacularDiseases (Axoplasmic Flow from Extra-Ocular Injections)

Described herein is not only a unique agent but a unique delivery systemfor the treatment of human macular diseases. Botulinum toxin has theability to diffuse from the injection sites affecting a regionalbiologic effect that is directly and volumetrically related to dose.Biologic effects on structures can be accomplished additionally byretro-grade and ante grade axoplasmic flow through autonomic, sensoryand motor nerves causing a change by genetic upregulation of proteinsgoverning cell to cell adhesions such as actin, various cadherins, andhaving a direct action to upregulate structural proteins governingmembrane barrier functions, cells adhesion to basement membranes anddifferentiation of the polarity of epithelial cytoplasm relating to thefunction of the epithelial barriers. The unique feature is very usefulin that intravitreal injections may not be necessary, in someembodiments. Elimination of this step in the treatment of maculardegeneration may reduce of eliminate the risk of vitreous hemorrhage,endophthalmitis, retinal detachment, traumatic cataract formation,glaucoma, retinal breaks, and pain associated with a direct injectioninto the eye. These complications can be devastating and may result inblindness.

A pharmacologic effect from injection of soft tissues around the eye isnot associated with the more serious, potentially blinding,complications which can occur with direct injections into the eye. Theseinjection locations may be less painful as well. Dosing of the disclosedformulations can vary between 1-3000 units, preferably 1-300 units andmore preferably 1-200 units (BOTOX®). Higher dosing can be used withless potent formulations (Dysport, Xeomen, Myobloc or otherpreparations). The injections are generally given over the regionsinvolving motor and sensory nerves which enter the eye, especially thetrigeminal nerve, oculomotor nerve, and most particularly autonomicnerves such as the pterygopalatine ganglion under temporalis muscle.Transport via venous system is also possible as periocular tissue in theforehead, lids and immediate surrounding anatomic regions drain directlyinto the orbit with collateral flow into the eye. Autonomic nerves alsosupply the human eye (pupillary fibers) and transport via collateralautonomic nerves can act as a conduit for a biologic intra-ocular effectdelivery from nerves penetrating the poster eye pole overlying themacular (see figure of orbital dissection). This conduit offers apassage for low concentration delivery of botulinum or its fragments tothe choroid and retinal pigment epithelium, possibly in concentratedforms. Sensory nerves can further this conduit to the target retinalpigment epithelium. Transcytosis is possible with penetration ofbotulinum material by retinal pigment epithelial and neuro retinalstructures affecting both blood vessel responsiveness to vascularendothelial growth factors, vascular permeability, barrier integrity ofthe retinal pigment epithelium, and potential for leakage and new bloodvessels growth from immunologic cytokines emitted from loss of integrityof the RPE barriers. This process allows botulinum toxin to enhance cellto cell adhesion via possibly modulating action on Rho kinase, ROCK, andother proteins critical in maintaining the RPE actin cytoskeleton, cellto cell adhesion molecules, cell to basement membrane adhesionmolecules, and endothelial adhesion molecules rendering the biologic RPEbarrier function more robust and inert as well as improve physiologicfunctions such as processing, catabolizing and removing rhodopsinprotein. Further, the effect of the botulinum toxin may prevent vascularleakage and/or diminish and stabilized vascular endothelial growth. Suchan effect can also involve the retino-vascular blood retinal barriers asoccurs in macular edema from inflammation and diabetes. Additionally,autonomic nerves have been shown to integrate with choroidal autonomicganglion cells under the macular.

Prior to the filing of the subject application, the intra-ocular effectsof botulinum toxin on RPE-retina were unknown. Moreover, it was notknown that injections of botulinum into skin of lids, face, forehead,facial bones, facial and jaw muscles, scalp sinus mucosa, nasal mucosa,neck, mouth or palate and in autonomic parasympathetic and sympatheticganglion which project axons into the eye had any effect whatsoever onthe RPE/choroid. This information alone is novel and, in combinationwith the disclosed formulations and methods can provide saferadministration paradigm than intra-ocular injections.

With respect to dosing using BOTOX® or other botulinum formulations(e.g., Dysport, Xeomen), a large dosing can be given in the para orbitalregion with causing diplopia. The pterygopalatine region is in closeproximity to the inferior orbital fissure, which directly communicatesinto the orbital. Doses under 200 units applied under facial muscles inthe temporal region have not led to botulinum diffusion and neuromuscular paralysis of extra-ocular muscles, causing diplopia. As this isan open anatomic region, a contrary effect with large dosing would beanticipated. In over 77 injections given by the inventor to patients, nodiplopia has been encountered with dosings of less than 200 units.

Penetration of the Internal Eye by Peri Orbital and Peri-OcularInjections

Another unique aspect of the disclosed therapeutic formulations andmethods is that an effect on the internal eye in the macular region canbe achieved by a peri-ocular or peri-orbital injection. Not to belimited to the high dose effects gained by pars plantar injection(discussed with respect to other embodiments), the opportunity to gainentrance into the eye by per-orbital lid, or peri-ocular and neckinjections using axoplasmic transport is an operational improvementwhich avoids serious complications of other methods. Extraocularinjections would easily be possible and much easier for patients.Extra-ocular injections targeting upstream nerves remote from the eyewhich eventually enter the eye allows for selective effect onintra-ocular contents without subjecting muscle tissue to the effects ofthe toxin causing extra-ocular muscle weakness with diplopia and ptosis.Positioning the injection needle deep into the orbit with resultingbotulinum toxin-induced paralysis of the extra-ocular muscles may beundesirable. The risk of repeated intra-ocular injections which cancause intra-ocular hemorrhage, eye destroying endophthalmitis, retinaldetachment or retinal breaks, lens dislocations, or increases inintra-ocular pressure. The toxin can reach the targeted choroid, retinaeby unique mechanisms such as axoplasmic flow, venous retrogradediffusion, and/or direct diffusion from peri-ocular and paraorbitalinjections. These indirect mechanisms for the treatment of AMD andassociated conditions afford a selective entry into the eye, novel initself, via nerve transport to avoid undesirable side effects frommuscle weakness.

Notably, the choroid nerve fiber structure has proven to be positive fora number of neuropeptide and related neurotransmitters. With age, therehas been noted to be a recession of nerves in the choroid in closeapproximation to the retinal pigment epithelium. Such denervation canrender a trophic effect on structure and function of the retinal pigmentepithelium to cause RPE dysfunction, loss of cell to cell adhesion andloss of vital RPE barrier function, as well as other structure andfunctional degenerative changes. Certain neurotransmitters, nervepeptides, present in the choroid can be vital to epithelial health andfunction. Recession and depletion of such chemicals can result inatrophy, mesenchymal and migratory changes in the RPE, loss ofRPE-photoreceptor interplay and ultimately photoreceptor damage withloss of retinal function and vision.

In the ocular surface case presented in the examples (filamentarykeratitis), loss of barrier function with cell to cell adhesion andepithelial cell adhesion to basement membrane strands of cornealepithelium break off form filaments exposing corneal sensory nervesresulting in pain and pathologic reactive changes (neovascularization).Filamentary keratitis is a common problem with corneal denervation and acondition called neurotrophic keratitis. Neurotrophic keratitis resultsfrom damage to sensory nerves from trauma, recurrent infection withneurotrophic viruses (e.g., herpes simplex, herpes zoster), chronicinfections, dry eyes, with mucous and tear deficiencies. The epitheliumis often degenerated prior to loss of corneal epithelium andneovascularization, a in a manner similar to macular degeneration. Inthe case described herein, topical botulinum toxin resulted in repairand mitigation of the filaments in a time course consistent with knownbotulinum pharmacokinetics and with repeated efficacy. Botulinum here iscausing increased cell adhesion to surrounding cells and basementmembranes and stimulating nerve structures in a fashion favorable tocorneal epithelial function and elimination of filaments breaking offthe continuous corneal epithelial sheet. Botulinum stimulatesnerve/epithelial structures to produce actin and related adhesionmolecules to that epithelium barrier function and structure isfacilitated and sensory nerves function is at least partially restoredover the pathologic state.

The epithelial discontinuity in such cornea cases proceeds to growth ofnew vessels. In the case of macular degeneration, the stage 1 dry formof macular degeneration precedes the growth of new vessels whichdestroys the RPE-photoreceptor interface leading to blindness. Avoidingthe discontinuity by enhancing nerve fiber effect from choroidal axonsand ganglion cells is a mechanism described herein which is useful forthe treatment of macular degeneration. The botulinum enhanced choroidalnerve fiber effect on the RPE provides function stability to the RPEallowing for enhancement of barrier function, maintenance and preventionof degeneration of the retinal pigment epithelium with time. Defects inthe choroidal innervation results in loss of important chemical derivedfrom peripheral nerves vital to RPE health. Loss of certainneuropeptides such as vaso-active intestinal peptide (VIP), have beenknown to be depleted in cases of macular degeneration. Leaching of thetoxin through the RPE or nerves surrounding arteries entering the eyecan also have an effect to seal leakage from retinal arterioles, leadingto the treatment of retino-vascular leakage.

Botulinum toxin by stimulation of peripheral sensory nerves to sustainand stimulate vital intra cytoplasmic structures, such as formativeactin molecules, and associated proteins, adhesion molecules, andneurotransmitters and RPE can be vital to maintaining RPE and delayingthe effects of macular degeneration. Botulinum toxin has a potent effectto stimulating actin-actin associated proteins formation on peripheralmotor nerves and such effects can carry over to the peripheral nervespenetrating the human eye.

Safety

Utilizing peri-ocular botulinum toxins is also safe. For cosmetic,facial movements diseases (hemifacial spasm, blepharopasm, Meigessyndromes, dystonia, bruxism, migraine, tension headache), crows feet,forehead lines, glabellar lines, induced ptosis, facial inflammatorystates, well-established dosing parameters have been designed to providean exquisitely high safety record. As the material is known to be verysafe after repeated injections, the unique opportunity is present toprovide patients with retina and macular diseases a superb opportunityto understand the risks benefits over existing FDA approved drugs(Eylea®, Lucentis®, and Avastin®). Most of the studies done over thelast 3 decades have had safety eye exams and no serious irreversible eyecomplication has been identified. This opportunity is truly unique forclinical studies and will serve as an impetus to proceed using variousendpoints such as acuity (such as defined in ETDRS-early treatmentdiabetic retinopathy study) and other endpoints mentioned herein.

The disclosed methods can limit applications of anti-VEGF agents (viaintravitreal injections) and enhance potency of these anti-VEGF agents,which can lead to enhanced duration of action. Moreover, this synergismserves to decrease the frequency of intra vitreal injections (thusincreasing safety by limiting the number of surgically-driven eye stabs)and increasing patient comfort. The disclosed methods can also decreasethe use of expensive agents for patient and government insuranceagencies (such as Medicare), allowing less expensive agents to achieve apotency and duration improvement over current (even long-acting) agents.

When a botulinum product is used in conjunction with an intravitrealanti-VEGF, it can be given prior to the intravitreal injection or afterthe intravitreal injections, in some embodiments. Repeated injections ofbotulinum toxin can be given for years with high levels of safety.

Trans-Neural Delivery to the Maculae

In some embodiments disclosed herein, the peripheral nerves are utilizedas a conduit to deliver botulinum toxin-based pharmaceutical into theeye, retina and/or macula without using a direct intra-ocular injection(which inherently increases the risk of complications). The smoothmuscle of the vessel walls of the choroid, like those of skeletal andcardiac muscle blood vessels are innervated by both divisions of theautonomic nervous system, which form dense plexuses of fibers around thevessels (“perivascular plexus”). Axon terminals are also foundthroughout the stroma, terminating on non-vascular smooth muscle,intrinsic choroidal neurons (ICNs), and possibly other cell types. Thereare also primary afferent sensory fibers that project to the trigeminalganglion via the ophthalmic nerve; some of these give rise topeptide-positive collaterals that terminate on and around the vesselsand intrinsic choroidal neurons.

FIG. 6 illustrated a human dissection orbit from above. In FIG. 6, thethin dark arrow represents a needle placement next to orbit. Noteproximity and presence of vessels and nerves in this region givingbotulinum toxin formulations access to the posterior surface of sclerawith nerve vessel penetration into macular and choroid-pigmentepithelium. Injections target autonomic nerves and/or sensory nerves inthe pterygopalatine fossa.

FIG. 7 illustrates extra-ocular administration followed by nervepenetration and transcytosis with eye penetration. Transport along axonsin each direction and transcytosis to achieve penetration into the eye(choroid, retinal pigment epithelium and neuroretina). Dendrite-axonpenetration, cells transcytosis to new axon and dendrite (retrogradepenetration and transport) may also be utilized in some embodiments.

The main parasympathetic input to the choroid originates from thepterygopalatine ganglion located within the pterygopalatine fossa (FIG.6). These fibers are predominantly cholinergic and are rich in thevasodilators vasoactive intestinal polypeptide (VIP) and nitric oxide(NO). These nerves are targets for botulinum toxin penetration andtransport into the eye when injections are given into the region of thepterygopalatine fossa (outside the eye and orbit). The sympatheticinnervation of the choroid comes from the superior cervical ganglion.These noradrenergic neurons terminate on the blood vessels and mediatevasoconstriction. This anatomic arrangement allows for neck injectionspenetrate the eye by axoplasmic flow.

The choroid has been shown to use peptides such as substance-P andcalcitonin gene-related peptide in a pre-central reflex arc, or axonreflex, a non-synaptic response in which a local stimulus (chemical ormechanical) depolarizes a sensory terminal which travels to the nearestcollateral (branch), releasing the peptide onto the effector tissue.Evidence for this reflex has been found in the primary sensory afferentsfrom the trigeminal ganglion in the uvea and choroid, which use bothpeptides; the reflex may mediate changes in blood flow or a variety ofother functions. For instance, in both mammals and birds, sensory fibersprojecting to the trigeminal ganglion from the choroid via theophthalmic branch of the trigeminal nerve elicit vasodilation. Theseterminals are positive for substance-P and calcitonin-gene-relatedpeptide.

Botulinum toxin may be transported via any peripheral neural pathcapable of collateral axoplasmic flow and, in some cases, can penetrateinto the choroid and into retinal pigment epithelial structures viatranscytosis to achieve a biologic effect on target tissues in themacula (see FIG. 7).

Venous delivery is not mutually exclusive of axoplasmic delivery to theeye. Diffusion into the cavernous sinus (venous sinus with carotidartery passing through the center) brings toxin molecules in proximityto the carotid syphon which contains sympathetic nerves throughout itssurface (sympathetic plexus). Binding of botulinum to autonomic neuronssurround the carotid artery surface in the cavernous sinus results inaxoplasmic flow along the ophthalmic artery into the orbit andeventually into the posterior eye and maculae with an effect onneuromuscular junctions.

Veins drain from the periocular region nasal region and via inferiororbital fissure in proximity to the orbital veins in proximity to thevortex veins draining the internal eye. Venous anastomosis allowsanother conduit for delivery into the choroid and retina.

Axoplasmic Flow (Unique Conduit for Entry into the Choroid and Retina)

Early experiments with radiolabeled full length BoNT/A showed that thetoxin is transferred to the ventral roots and adjacent spinal cordsegments upon intramuscular injection in the cat gastrocnemius.Similarly, radiolabeled BoNT/A has been shown within the axoplasm ofmyelinated axons after its peripheral injection in mice. Adose-dependent retrograde transport of BoNT/A in brainstem motor neuronswas also shown by electrophysiological and ultrastructural experimentsin cats. Further segments of botulinum toxin have also been noted toundergo axoplamic flow (HcA segment). Both full length botulinum toxinand binding segmental forms can undergo long range transport viaaxoplasm. This phenomenon is exploited in one delivery mechanismdemonstrated in the invention and case examples. In compartmentalizedcultures of rat sympathetic neurons, BoNT/A moves retrograde into cellbodies when applied at high concentrations into the distal compartments.However, retrograde trafficking of BoNTs has been inferred mainlyindirectly, i.e. by observing the appearance of radioactivity orBoNT-cleaved substrates away from the site of administration. Thus, thekinetics and intracellular pathways used by BoNTs for their long-rangetransport remains unclear but more recently tracking SNAP 25 lysisactivity along the neurons axon and cell body over time has been helpfulin substantiating initial observations. Transcytosis has beendemonstrated and is operational in various embodiment of the invention.

In addition to axoplasmic transport and effects on choroid and retinalstructures, botulinum toxin A or its segments and associated proteinscan be used in unison or as part of a fusion protein complex involvinganti-VEGF proteins to achieve higher and more sustained biologic effectsto enhance barrier function, stop leakage and regress neovascularizationand its pathologic effects, and/or alter intracellular RPE structuralprotein expression. A combined molecular approach provides for analternate method for bringing an anti-VEGF drug to the choroid withoutand intra-ocular injection and using a carrier protein which furthertargets a cellular mechanism involving retinal pigment epithelialintegrity. Such a formulation may involve use of one or more of thefollowing: botulinum toxin (for instance, a subtype of type A) orfragment (for instance HcA, binding domain), a fusion addition of ananti-VEGF agent (for instance, a non-fused addition of an anti-VEGFagent, Avastin® or another fusion protein with anti VGF properties), anda stabilizing excipient known to facilitate stability and nerve cellaxonal uptake.

The anti-VEGF agent can be delivered by botulinum or its fragments whichparticipates by axoplasmic flow and undergoes transcytosis with theanti-VEGF agent causing a multifaceted mode of action causing reversalof leakage from new vessel growth, regression of new vessels,enhancement and promotion of a robust retinal pigment epitheliumintercellular attachments to basement membranes and contiguous cells anda reversal of intracellular structural proteins which foster RPEdegeneration. This formulation may also react with retino-vascularcirculation to limit leakage from the retino-vascular capillaries andpost capillary small veins.

The disclosed formulations may be used with conventional para planainjection, intra-ocular injection, or other types of extraocularinjection. Additionally, in some embodiments, one or more fusionproteins and axoplasmic transport may be used to produce uniqueformulations. The disclosed formulations can be used with theconventional para plana injection (intra ocular) of anti-VEGF agents toproduce a potency enhancement with respect to using a single anti-VEGFalone (see example), in some embodiments. Further, one or more anti-VEGFagents can be included with a botulinum toxin formulation describedherein and applied via an extra-ocular delivery method (as describedherein) to produce enhanced potency.

Para-Orbital Injection of Botulinum Toxin for AMD

As previously described, extra orbital injections of botulinum toxin canresult in delivery of botulinum toxin to the macular via axoplasmicflow. An anatomic arrangement conducive to macular delivery involvesplacing the needle over the zygomatic arch aiming the bevel toward thepterygopalatine fossa and in proximity of the external portion of theinferior orbital fissure. The inferior orbital fissure extends veryanteriorly (unlike the superior orbital fissure), allowing a 2 cm needleto very closely approach the fissure. Projection of the pterygopalatineganglion, which projects through this fissure, supplies the globe andallow botulinum toxin close proximity to autonomic synapses as well asveins which drain toward the cavernous sinus. Penetration of botulinumtoxin into the globe from this injection point may be facilitated bythis anatomic arrangement. Toxin in cavernous sinus veins can infiltratethe sympathetic autonomic nerves on rout the retina via ophthalmic,retinal arteries and ciliary arteries (countercurrent movement ofbotulinum toxin nerve vs vein). The ganglion noted in the human choroidmost likely picks up its innervation by the pterygopalatine ganglion.These ganglions are often seen in close proximity to the posterior poleof the globe. This unique injection location is devoid of major vesselsand critical structures, resulting in a very low risk procedure. Sensory(V2) and autonomic nerves are closely abutting the fissure and thefissure may allow some orbital and globe penetration. In these and otherembodiments, other para orbital areas may also be used as injectionpoints.

Conversion Table:

For BOTOX®, 1 unit roughly corresponds to 3-7 units of Dystport 0.8-2units of Xeomen, and 20-150 units of Myoblock. Other formulations may betested with the conventional mouse LD 50 assay and converted to the LD50 standard derived from the Hall Strain derived type A₁ for comparativeunit potencies.

Rho Kinase

A unique aspect of the invention described herein is that type Abotulinum toxin has Rho kinase modulating action and can affectexpression of actin and cadherin important in preventing apoptoticchanges in cell structure (programmed cell death cycles). Botulinum typeC3 has been long known to have highly significant Rho kinase activity.Herein the effect from immunotype A of botulinum toxin is achieving sucheffects similar and identical at regional dosing levels below necessaryto cause muscle weakness with attendant dysfunction such as diplopia lidmalposition's and eyelid weakness is an operational component of theinvention. Rho Kinase can effectively interact with the actincytoskeleton causing anabolic gene expression, enhancing rapid turnoverand expression of actin in such as fashion as to alter and enhance cell,tissue and organ function. Effects on other ocular tissue pertinent toRetinal Pigment Epithelial Interaction (Filamentary keratitis) arediscussed relative to Example 3.

The effect on epithelial barriers has been demonstrated in anotherocular condition known as filamentary keratitis, which can serve as asurface model for the understanding effect on the RPE. This is acondition often associated with dry eye syndromes, and inflammatorysyndromes characterized by epithelial strains separating from attachmentto the epithelial sheet and underlying basement membranes. The processin a predisposed patient can be chronic and be associated with visualloss, pain, photophobia, and involuntary eyelid closure. Botulinum toxinhas been used to close eyelids to treat various forms of corneal ulcersin the past to mimic a surgical tarsorrhaphy, an operation used to closethe space between eyelids (palpebral fissure) and protect the ocularsurface. In these descriptions, no mention has been made about theintrinsic effect on botulinum toxin on the epithelium, cellularstructure of the epithelium, intrinsic effect of botulinum on cell tocell adhesion, cell to basement membrane adhesion from a direct effectof botulinum on adhesion molecules, or an effect on actin-cadherinproteins or any intra or extracellular proteins causing an increasedcohesion of corneal epithelium

Herein describes an intrinsic effect on corneal epithelium in whichincreases the cohesive integrity of corneal epithelial cells whichimprove symptoms of filamentary keratitis, with reduction anddisappearance of filamentous. This condition has been treated byconcepts describes herein with topical botulinum drops which gain accessto the epithelial cells on the eye surface via topical applicationdefects created by the disease. Botulinum toxin causes expression ofactin, enhancement the expression and intra-cellular organization ofactin, cadherin and associated proteins, which enhance epithelialcohesion and integrity causing diminished filament formation and diseaseimprovement. A similar effect in achieve in macular degeneration whichthe retinal pigment epithelium achieves an increased integrity frompromotion of cell to cell, cell to basement membrane and enhancespecialization of intracellular-extracellular function created by thebotulinum toxin based agent. With topical (eye drops) use of botulinumtoxin, beneficial effects on epithelial structures can be achieved.

For filamentary keratitis, botulinum toxin is directly observed to:

-   -   1. Enhance epithelial sheet adhesion on the ocular surface using        a slit lamp bi-microscope on the human eye    -   2. Decreased exposure of underlying nerves    -   3. Decrease corneal neovascularization in chronic conditions    -   4. Decrease pain from covering exposed nerve endings    -   5. Enhanced and rejuvenated microvilli on micro anatomic        structure of the epithelial surface causing a vital enhancement        of corneal integration with the tear film (needs for oxygen        transportation). Such microvilli improvement can be useful in        administering botulinum toxin for dry eye syndromes and        inflammatory conditions of the ocular surface such as recurrent        erosions.    -   6. Decreased incidence of recurrence

Similar effects can be used to treat other forms of keratitis involvingbasement membrane such as recurrent corneal erosion, basement membranedystrophy (map dot fingerprint dystrophy0, trophic corneal ulcers,herpes simplex keratitis, thyroid related eye surface disorders, cornealmelt syndromes, chemical burns, ocular cicatricial pemphigoid, chronicdry eye syndrome, rosacea keratitis, Stevens Johnson syndrome, andexposure keratitis. Topical formulations can be devised as many of theaforementioned conditions occur on or near the ocular surface.

Topical formulations containing larger concentration of botulinum toxincan enter the eye and provide a superior method of administration overpars plana intra-ocular injections.

Botulinum Toxin Formulations

Example botulinum toxin formulations include type A1-5, B, C1-C3, D, E,F, and/or G botulinum toxin. Fragments of botulinum toxin may be used toelicit specialized cellular effects including isolated genomicexpression of cellular constituents involved in enhancing barriereffects, actions on VEGF related pathways, interactions with presentlyavailable anti-VEGF drugs, structural proteins, regulators of structuralproteins, and inflammatory regulating proteins. The disclosedformulations may, in some embodiments, include stabilizing proteins,poly cationic proteins or permeators (albumin or polycationic proteins),use of lidocaine within preparation or given prior to injections,protein derivative from botulinum with SNAP-25 interactive portionschemically removed, formulations with enhanced hemagglutinin proteintypically found in the botulinum complex, enhancement with cadherinbinding proteins or agents know to act on Rho kinase, upstream anddown-stream metabolite and (ROCK). Modulation of ROCK by botulinum toxincompositions described herein (e.g., type A toxin) contributes totherapeutic effects for many disease conditions described herein.

ROCK1 is a protein serine/threonine kinase also known as rho-associated,coiled-coil-containing protein kinase 1. Other common names are ROKβ andP160ROCK. ROCK1 is a major downstream effecter of the small GTPase RhoAand is a regulator of the actomyosin cytoskeleton which promotescontractile force generation. ROCK1 plays a role in cancer and inparticular cell motility, metastasis, cells adhesion, and angiogenesis.ROCK1 has a diverse range of functions in the body. It is a keyregulator of actin-myosin contraction, stability, and cell polarity.These contribute to many progresses such as regulation of morphology,gene transcription, proliferation, differentiation, apoptosis andoncogenic transformation. Other functions involve smooth musclecontraction, actin cytoskeleton organization, stress fiber and focaladhesion formation, neurite retraction, cell adhesion and motility.Modulation and/or inhibition of ROCK1 influences reduction of stressfiber formation in RPE cells. Stress fibers formed by actin condensationin the RPE cytoplasm often occurs in age related macular degenerationcausing RPE barrier function disruption and downstream reactionsincluding neo vascularization, impaired RPE fluid pumping activity,immune exposer of the neuro-retina, influx of neuropeptides, cytokines,and complement. Stress fibers in RPE cells are depicted in FIGS.14A-14D, as well as in FIGS. 4C, 5A, and 5C. Furthermore, botulinumtoxin formulations described herein can be considered to promote retinalneuronal regeneration by changing Rho activity. These formulations caninclude, in some cases, botulinum complex typically known as BOTOX®(type A botulinum toxin complex).

Formulations are preferably given by injection but may be delivered withan eye drop. Eye drop deliverer may vary between 10-10,000 units butpreferable under 3,000 units. Alteration in dosing with differentformulations can be derived from the literature.

Preferably, Type A (or subtypes) or type B would be used as the safetyof dosing forms are well established for the existing preparations butother subtype and non-neuromuscular subtypes or chemically altered typesof botulinum type A are anticipated to be useful.

A botulinum toxin formulation comprising only hemagglutinin proteinsdevoid of neurotoxin can also be used to isolate and enhance the effectsof hemagglutinin on adhesion proteins such as cadherin isoforms andassociated intracellular proteins so as to allow for greater biologiceffects not limited by the weakening and paralytic effects of theneurotoxin. Further, in a unique embodiment, a formulation withneurotoxin with cleaved portion removing the SNAP-25 and neuromuscularweakening effect but preserving the effects on actin and cell adhesionfunction can be used for treatment. Such formulations have been citedand studied in past but have not been suggested for use in medicalindications such as macular degeneration or use on membrane barrierfunctions beneficial for the treatment of disease described herein.

Formulation consisting of toxin derivatives with cleaved SNAP 25activity can also be used as carrier molecules for anti-VEGF agents aswell as in conjunction with accessory proteins.

A botulinum toxin formulation comprising enhanced quantities ofbotulinum related hemagglutinin proteins with neurotoxin can be used toisolate and enhance the effects on cadherin and related adhesionproteins and associated intracellular proteins so as to allow forgreater biologic effects not limited by the weakening and paralyticeffects of the neurotoxin. In some embodiments, some such botulinumtoxin formulations can exhibit pharmacologic effects when injecteddirectly into intraorbital, intra muscular, conal, or subconjunctivalregions without causing diplopia.

Epithelial to Mesenchymal Cell Transformations and Botulinum ToxinEffect

Generally, most forms of macular degeneration involve a metaplasia ofthe retinal pigment epithelium. This process has been described as aconversion of the RPE cells to a fibrocystic cell capable of migratinginto the neuro-retina or vitreous of the eye. The process importantlyinvolves break away of the transformed RPE cell from its continuoussheet with reduced cell to cell adhesion allowing for membranedisruption (see FIG. 1B and FIGS. 5D-5F) and possible antigenicrecognition of inflammatory cells in the choroid to initiated leakageand growth of new blood vessels. Further growth of new vessels from thechoroid most often leak causing an accumulation of cytokines and toxicdischarges into the neuro-retina.

Botulinum toxin formulations described herein essentially have theeffect to retard or even reverse this process by causing expressionand/or modulation of actin, maintaining cell differentiation andstructure towards maintaining barrier function, halting the epithelialto mesenchymal transformation of the retinal pigment epithelium andeffectively arresting both major forms of macular degeneration (wet anddry).

Because of the impaired conversion to mesenchymal forms from the retinalpigment epithelium by botulinum toxin formulations, it is possible totreat or provide prophylaxis against proliferative vitreoretinopathyfollowing various forms of retinal detachments, a leading and oftenblinding complication of corrective retinal detachment surgery.

Vortex Blood Flow in the Human Choroid, Uveal Scleral Pump and BotulinumToxin Effect (Flow-Related Pressure Effects on the Choroidal Pump)

Botulinum toxin has been known to affect blood flow in certain vascularbeds causing a reduction in ischemia. This has been most commonly usedto reduce Raynauds phenomena, particularly in the setting ofscleroderma, a collagen vascular disease associated with fingertipischemia, necrosis and auto-amputation. Such effects may be the directresult of botulinum on smaller to mid-size arteries or an effect onautonomic nerves regulating blood flow to finger circulation.

As described herein, blood flow can be enhanced in the human choroid bybotulinum toxin injections remoted from the human eye or orbitalcontents, which do not cause neuromuscular weakness and effect anincreased suction pressure on the base of the retina, removal of fluidfrom physical effect relation to Bernoulli's principle, removal of fluidfrom neural retina, and mitigation of the progression of various stagesof macular degeneration (e.g., Drusen, drusenoids, pigment migration,and sub retinal and intra-retinal fluid).

Arterial perfusion to the choroid of the internal eye is mediated bybranches of the ophthalmic artery entering via the posterior pole of thesclera with breakout to the long and short ciliary arteries which enterthe eye providing a radially-oriented circulation path throughout thechoroid of the eye. The choroid, on a flow per cubic mm basis, is themost vascularized tissue in the human body and accounts for about 95% ofblood flow in the internal human eye. The flow leaves the anteriortoward to cavernous layers entering a capillary net (choriocapillaris)just under the retinal pigment epithelium and finally enters the venousdrainage system an exits eye through the vortex veins underlying thechoroid.

A previously unappreciated aspect of this arrangement is the changes indirectional movement within the choroid from radial flow entry to a flatcircular drain with forward flow conversion into a circular vortexdirected under the retinal pigment epithelium. This change isre-enforced by the net-like organization of the choriocapillaris.Circular flow with small lobules or larger groups of lobules creates awhirlpool effect, causing suction on the base of the retinal pigmentepithelium. The organization of circular flow in addition to thewhirlpools oriented in similar spine direction as related in the venousdrainage into the vortex veins can be observed in fundus photography andfluorescein angiogram in a human albino choroid which can be studiedbecause of absence of image blocking pigment in the RPE. This whirlpooleffect has been named as the Charybdis effect after the whirlpoolmonster descried in the Odyssey (Homer). The whirlpool in the Odysseysucked ships into the abbess destroying ancient ships. In the eye, theeffect is possible providing a pumping mechanism to:

1. Remove waste products and metabolites from the eye;

2. Provide suction for proximity of rods and cones into the retinalpigment epithelium;

3. Provide movement of fluid through Bruch's membrane at the base of theretinal pigment epithelium;

4. Pressure effects regulating the genomic expressions favorable tobarrier membrane integrity, cell adhesion integrity, and barrier effects(Pressure effects can drive uveoscleral flow is a positive direction forand fluid removal from the neuro retinal and sub retinal space.);

5. Provide an enhance fluid removal mechanism to the neuro retina forcases of wet macular degeneration or leakage from other causes mentionedherein by enhancing choroidal blood flow;

6. Delay the development and progression of drusen, barrier integritydisruption of the RPE, and forces holding the RPE to Bruch's membrane;

7. Enhance and maintain the genomic of highly differentiated RPE andsuppress EMT transformation and migration of the RPE into theneuroretina;

8. Provide a suction force clearing large molecules such as fatscholesterol clearing accumulation on Bruch's membrane, which contributesto cracks and leakage and ultimately to AMD progression;

9. Provide rapid clearance of inflammatory cytokines; and

10. Enhance phagocytosis of RPE with rod and cone projections.

Increasing blood flow by effects of botulinum toxin or its fragments ininjection formats described herein can cause preservation andenhancement in choroidal blood flow, including the choriocapillaris,increased choroidal pumping action, maintaining functions of thechoriocapillaris, arresting or retarding progression of maculardegeneration, and decreasing fluid accumulation in the macula (see FIG.18C). The disclosed methods are thus capable of preserving thechoriocapillaris and its function(s) with repeated injections ofbotulinum neurotoxin.

The above system can be targeted not only by botulinum toxin, butbotulinum toxin used in conjunction with other accessory agents thatenhance blood flow to the choroid. Accessory agents that can increaseblood flow in certain circumstances include but are not limited to:phosphodiesterase type 5 (PDE5) inhibitors (Viagra™, Cialis™,sildenafil, tadalafil, and vardenafil), nitrates (e.g., Isosorbide),statins (e.g., Atrovastin), niacin, marijuana, flavonoids,prostaglandins and prostacyclin analogues, agents producing NO (nitricoxide), and/or fish oil.

Targets for Therapy in the Clinical Setting

The disclosed formulations and methods may, in some cases, improveand/or maintain vision in patient afflicted with macular degeneration.Further, the botulinum toxin can be used to reduce anatomic changes inpopulations at risk for macular degeneration.

Functional measurements can involve various forms of visual acuitytesting, contrast sensitivity testing, visual fields, anatomic outcomemeasurement using coherence retinal tomography or fluoresceinangiograms, color vision, OCT, light dark adaptation measurements, orany other measurement of visual function.

The disclosed formulations may be used for one or more of the following:

-   -   1. Prophylactic in high risk populations as determined by        genetic testing or strong family history    -   2. Arrest progression of dry degeneration to neo vascular stage        with attendant leakage    -   3. In wet stage to both enhance drying and decrease choroidal        leakage from recession of choroidal neovascularization.    -   4. Use of an enhancer of existing anti-VEGF agent to increase        potency and duration of action allowing for fewer intra-ocular        injection procedures.

An approach to treating dry macular degeneration involves maintainingthe barrier between the neurosensory retina and choroid the source ofneovascularization. As such an application involves making injectionswith barrier enhancing agents at the level of the retinal pigmentepithelium, such injections would need to be extra-ocular to achieve arisk benefit ratio suitable repeated dosing in a patient with stage 1 orearlier stages of macular degeneration with leakage. Botulinum toxin viaextra-ocular injections would be ideal as the safety factor are wellknown to be favorable for peri-orbital and facial injections at dosinglevels described herein. Such repetition can provide a prophylactic forearly macular degeneration cases progressing to stage 2 (wet variety)which is associated with a rapid deterioration in visual acuity andreading potential.

Botulinum Toxin Hemagglutinin in the Complex, Free from Muscle WeakeningNeurotoxin, and Role in the Macular Application (VEGF Action)

For the first decades of botulinum use in humans, the toxin has beenadministered as a complex of neurotoxin associated with non-covalentlybound proteins. The type A molecule is composed of neurotoxin,hemagglutinin proteins, and non-hemagglutinin, non-neurotoxin proteins.Most publications to date have indicated the latter two proteins have norole in clinical application of injectable botulinum toxins for variousdisease states and cosmetic applications.

The non-hemagglutinin may stabilize the formation to shelf life and thehemagglutinin has been shown to be important in to trans epithelialpenetration and toxicity to orally ingested botulinum toxin andinfluence oral ingested toxicity. The hemagglutinin makes the complexmore toxic by promoting gastric absorption. Collectively, these proteinsmay enhance in part or when used in combination the effects on the humanretinae causing benefit to macular degeneration.

Contrary to the above, the macular and other epithelial applications tobotulinum toxin are influenced by adjuvant proteins within theformulation. In fact, such proteins can be used enhancers, independentpharmaceutical agents to enhance botulinum potency on epithelialstructures involving eye applications, and can have substantial directedbiologic effects even when used in the absence of neurotoxin.

The examples given herein used BOTOX®, which is a complex withhemagglutinin adjuvant proteins. Botulinum toxin derived hemagglutininshave a direct action on cleaving cadherin E, a critical proteinmaintaining tight junction between gastric epithelial cells allowing forincrease uptake of the botulinum neurotoxin increasing its toxicity.Further and even more remarkable relative to the retinal and eyeapplications, this effect (contrary to publications) can have an effecton various cadherin types causing a critical interaction with importantreceptors involved with endothelial cell growth (neovascularization.)Example 1 showed evidence of improvement in leakage and recession of asub epithelial neo vascular membrane which is associated with improvedprognosis for macular degeneration progression. Further, the effect ofBOTOX® impedes differentiation of the RPE cells into mesenchymalfibrocytes which attendant death of neuro-retinal photoreceptors.

Cadherin cell connector proteins have been implicated in a number ofretinal diseases including juvenile macular dystrophy, butterflydystrophy, Ushers syndrome, autosomal recessive rod-cone dystrophy. Anumber of typed polymorphisms to cadherin genes have been linked tothese macular and retinal conditions, which effect appearance anddegeneration of the RPE. The unexpected result is that cadherin activityvia botulinum complex or hemagglutinin known to act on cadherin lysiscan in fact cause re-expression of cadherin cell connecting proteinwhich enhance barrier activity.

Cadherin VE is known to be an important protein contained withinvascular endothelium important to vascular integrity and growth of newblood vessels. Cadherin VE not only mediated adhesions betweenendothelial cells but is required for endothelial cell survival andmaintenance. Vascular endothelial growth factor (VEGF) requires forms ofcadherin to bind to its receptor tyrosine kinase to maintain and actuateendothelial growth. To this extent the hemagglutinin with the complexwith or without the neurotoxin can act as an anti-VEGF agent capable ofenhancing the effects of Avastin®, EYLEA®, or other forms of anti-VEGFdrugs. The use of botulinum toxin with hemagglutinin can provide anaction on VEGF function so as to inhibit activity and growth of vessels.This effect augments applications of retinal pigment epithelial barriersfunction, attachment to basement membrane, cell polarity, microvilliprojections, desmosome integrity, and function of the retinal pigmentepithelium also produced by the botulinum toxin based formulation.

The serendipity of these observations and applications is thatquantities of hemagglutinin have been present in Botox-Occulinum® foryears and safety factors of these quantities have been tested innumerous clinical studies, which have demonstrated a very high degree ofsafety. The complex has been demonstrated to disassociate quickly fromthe neurotoxin component once injected into a subject indicating freecomplexing protein are well tolerated not producing complications andsubstantial adverse events. Further isolates of the hemagglutininprotein via ion exchange or other forms of protein separations allow forthe development of possibly more directed pharmaceuticals formulatedbeing a specific anti-VEGF for the treatment of macular degeneration.Not to be limited by mechanism, the case reports presented herein provedthe substrate to formulate theory and practice both from observation,unexpected pharmaco dynamics (eye penetration) and important medicinaleffects consistent with the novel applications described herein.

Hemagglutinin derived from botulinum toxin can be recombinant producedand purified by removing the neurotoxin from the formation. For type Abotulinum and its various subtypes, the final produced may be tested forweakening capacity using regional and mouse LD 50 assays to assure noresidual neurotoxin is left in the formulation. The formulation may beadministered in a pier ocular peri orbital or intravitreal form in dosequantities that have no effect on red cell agglutination but in a dosingformat capable of suppressing neovascularization and retinal pigmentepithelial cell leakage and vascular growth under the retinal pigmentepithelium.

Botulinum Toxin Complexing Proteins

All naturally occurring serotypes of botulinum toxin (types A-G), havenoncovalent associated, complexing proteins and thus forms toxincomplexes. Complexing proteins are encoded in two gene clusters locatedclose to each other on the C. botulinum chromosome. The first clusterencodes botulinum toxin itself plus a nontoxic, nonhemagglutinin (NTNHA)protein, while the second encodes three hemagglutinin (HA) proteins(HA1, HA2, and HA3), with HA3 being cleaved in serotype Apost-translationally into two smaller components (HA3a and 3b). Inbotulinum toxin serotypes A-D and G, these components form two differenttoxin complexes (i.e., a medium toxin complex comprising botulinum toxinand NTNHA (300 kDa) and a large toxin complex that also includes thethree HA molecules (500-600 kDa)). In contrast, serotypes E and Fproduce only the medium toxin complex. Serotype A also forms a thirdcomplex with a higher molecular weight (900 kDa). The detailed molecularstructure of botulinum toxin type D large toxin complex has beenvisualized and comprises a 14-subunit complex of neurotoxin, NTNHA,three HA3 molecules (a 70 kDa molecule, also known as HA-70), three HA2(also known as HA-17), and six HA1 (also known as HA-33) A denaturingcapillary electrophoresis method can determine the subunits forming thevery large/or higher molecular weight toxin complex of botulinum toxintype A, concluding that it contains single copies of the 150 kDaneurotoxin and NTNHA subunits, as well as 5-6 HA-17, 4-5 HA-23, 3-4HA-48, and 8-9 HA-34 subunits, with a total mass of 880-1000 kDa.

Any component of botulinum toxin hemagglutinin would be candidate forassessment of Biologic Activity as an Anti-VEGF agent, cell to cell,cell to basement membrane or cytoskeletal stabilizing agent or an agentuseful in application toward eye diseases described herein. Theformulation may include neurotoxin with the complex proteins, any one ormore of the complex proteins or component of the complexing proteins.

Enhancing the quantity of hemagglutinin in existing formulations isanticipated and can be useful for the treatment of spasticity conditions(post stroke and cerebral palsy), blepharospasm, hemifacial spasm,torticollis, prostate hypertrophy, plantar fasciitis, bruxism, arthriticconditions, myofascial pain, migraine headache, tension headache, majordepression (MDD), anxiety, and wound healing. The inventor has observedinflammation as a sensitizer for worsening of many of the aforementionedconditions which can be addressed by higher quantities or enhancedquantities of botulinum toxin derived hemagglutinin to existingformulations to achieve a more potent effect.

Dose of HA and Dosing at Higher Concentrations than Previously UsedAnticipated

As botulinum as Botox® has been used for decades quantities of HAderived from botulinum toxin type A complex (see Schantz Therapy withBotulinum Toxin) are anticipated to be at levels commonly used varyingbetween the quantity associated between 5 U-8000 U (1 U=LD 50 for awhite mouse). Most preferred is the quantity of hemagglutinin associatedbetween 5-4000 U.

Topical Formulations of Isolated Botulinum Toxin Derived Hemagglutinin.Injectable Formulations Applications

Higher dosing with botulinum toxin associated hemagglutinin (dosesassociated with excess of 800 U of botulinum complex) are possible asthe lethal component of the complex (neuro-toxin) is not present sosystemic weakness is not limited by doses. Inherently this conceptallows for unique dosing forms free of paralyzing toxin.

Topical formulations of hemagglutinin derived from botulinum toxin is aviable composition at dose described herein for limiting new vesselsformation and scaring on the human cornea from various infections(herpes virus, rosacea, ocular cicatricial pemphigoid, traumatic injury,exposure keratitis, corneal graft rejection, alkaline burns, socketinflammation, or other infections degenerations or dystrophies to thehuman cornea. Aerosols botulinum derived hemagglutinin are possible toprevent, vascular leakage and treat scaring in lungs, upper respiratorysystems, esophagus, pharynx, intestinal tracts, nasal mucosa, rectalregion. Infusions via intraperitoneal can be used to prevent scaring inthe peritoneum and surface of the large and small intestine. Intravenousinfusion can be used to mitigating new vessel growth into malignanttumors, which promote neovascularization such as metastatic tumor to theliver, spleen, lungs, brain, and other organs. Use in allergy isanticipated as well as autoimmune disease, such as Graves disease andauto-immune thyroid disease. Use in various forms of uveitis, to preventexudation and leakage is anticipated by per-ocular, intravitreal, orintravenous injection. Treatment of leaking blood vessel associated withdiabetic retinopathy and blinding diabetic neovascularization can betargeted by the “anti-VEGF” component action of botulinum toxinhemagglutinin activity. Chronic asthma with vascular leakage andscarring can also be targeted, in some embodiments. Eczema andinflammatory skin diseases can be targeted. Various forms of sinusitiscan be targeted for treatment. Use in IGE mediated edema can also betargeted. Other inflammatory conditions can be anticipated for ananti-VEGF action.

The novel use of isolated hemagglutinin for macular degenerationcircumvents issues related to induced paralysis from the neurotoxincomponent of the molecule allowing larger dosing of the hemagglutininthan possible when the hemagglutinin is used with a complex with muscleparalyzing neurotoxin.

Extension of Invention to Other Forms of Disease Involving the RetinalPigment Epithelium

Other forms of disease of the retina can be targets for botulinum toxingiven by extra orbital and/or per-orbital method, including:

-   -   1. Retinitis pigmentosa (RP), recessive, x linked and dominant        forms    -   2. Best disease    -   3. Stargardts disease    -   4. Pattern retinal and macular dystrophy    -   5. Chloroquine retinopathy    -   6. Lattice dystrophy (with and without retinal breaks)    -   7. Angioid streaks    -   8. Birdshot retinopathy    -   9. Central serous retinopathy    -   10. Ocular histoplasmosis syndrome    -   11. Irvine Gass syndrome    -   12. White dot syndromes    -   13. Trauma to retinal pigment epithelium    -   14. Ocular Toxoplasmosis syndrome    -   15. Ocular conditions associated with pseudo exfoliation        syndrome    -   16. PVR (post-operative proliferative vitreoretinopathy)    -   17. RPE damage associated with choroiditis    -   18. Macular hole (partial and complete)    -   19. Early and late stages of Retinal Detachment (both        rhegmatogenous-break related and non-rhegmatogenous, non-break        related).    -   20. Diabetic macular edema    -   21. Diabetic retinopathy (any stage) (both retino-vascular        barrier effect enhancement by botulinum toxin, and RPE        enhancements in barrier and fluid leak functions)

In each of the above diseases disruptions of the retinal pigmentepithelium can occur causing damage to photoreceptors by leakage ofchoroidal fluid containing cytokines, leukocytes, antibodies and variousimmune reacting agents destructive to photoreceptors leading to visualloss and blindness.

Agents that augment the epithelial barrier elicit an increased integrityof the pigment epithelial barrier enhancing the protection of thephotoreceptors and visual function, even in conditions not associatedwith age related macular degeneration. Further botulinum toxin can havean effect on neuropeptide and other agents of neurogenic inflammationwhich when transported to choroid acts to suppress barrier damage andsubsequent visual loss associated with macular degeneration as well asother forms of degenerative and inflammatory diseases. Further, even ifeffects do not address genetic causes or other processes, theenhancement of the RPE photoreceptor system can be neuroprotective forphotoreceptors by mechanisms of enhancement of RPE function supportingthe phagocytosis, transport of apical rod cone structures.

In the case of retinal degeneration such as retinitis pigmentosa, thedefect may involve primarily the photoreceptors with retinal pigmentepithelial changes being secondary to excessive degenerative rod andcones material undergoing phagocytosis with toxic accumulation inretinal pigment epithelial cells followed by RPE degeneration anddysfunction. An agent which may augment the RPE tolerance for toxicprotein accumulation will retard visual deterioration based on RPE loss.Other mechanism at the level of the photoreceptors can play a role.Stabilization of barrier membranes with endothelial cells may further beoperational in preventing or migrating against progression ofphotoreceptor damage and protection. The cause of macular edema in RP ispossibly related to inflammatory autacoids and antibodies entering theneuroretina and elicited a breach in the blood retinal barrier at theretinal circulation. The edema suggests that RPE leakage fromvascularized choroid may be important in the progression of RP. Furtherintrinsic functions of the RPE such as preservation of microvilli,increased efficiency of phagocytosis based on actin stimulation insubmembrane regions, increased metabolic turnover of accumulateddysfunctional rhodopsin protein in the photoreceptors can play a role inreducing the visual loss over time in the various forms of retinitispigmentosa.

Genetic defects have been associated with retinitis pigmentosa, ahereditary condition associated with night blindness and degeneration ofrods and cones in the neuroretina leading to progressive and oftenrelentless loss of vision.

Proliferative Vitreal Retinopathy (PVR) and Epithelial MesenchymalTransformation (EMT)

PVR is one of the most devastating complications occurring after retinaldetachment surgery. The reaction of the RPE here is to undergo EMT withproliferation of cell into the vitreous with conversion to fibrocytesleading to traction membranes causing recurrent retinal detachmentswhich are poorly treated with existing measures. The application ofbotulinum toxin by extra ocular or intra-ocular administrationstabilizes the retinal pigment epithelial from fibrous and migratoryconversions leading mitigation of the fibrotic conversion surroundingretinal detachment surgery. Application as a prophylactic before, duringand after the surgery proves useful measure to decrease incidence andprogression of this complication.

Pseudo-Exfoliation Syndrome is still another condition associated withabnormality in cell to cell adhesion. Here migration of pigmentepithelial cell from uvea can often causes glaucoma by cell accumulationin the trabecular meshwork. Use of botulinum toxin by intra ocular orextraocular injections can result in tightening of the adhesions betweenpigment cells leading to less pigment dispersion, allowing a novelmethod to treat this disease. Further, this condition can be associatedwith higher cataract surgery complication rate from lens and zonuledislocation. This agent can be used for stimulating a tighter connectionbetween pigment epithelium and zonules.

In some embodiments, formulations comprising botulinum toxin may beinjected or topically applied to a patient for the treatment of surfaceepithelial ulcers and stabilization of biologic tissue barriers.Botulinum toxin has conventionally been used to treat spasmodic musclecontractions, relax muscles causing effects on muscles tone, blockingautonomic function causing secretions, causing diminished sensation ofpain such as headaches of various causes, and smoothing muscle generatedskin wrinkle. Application to non-muscular portions and regions of skincan cause epithelial tightening by the mechanisms described herein.

Another novel application of botulinum toxin which when used topicallyor by injection causes a rapid healing of an epithelial ulcers orstabilize biologic tissue barriers disrupted by various diseaseprocesses other than macular degeneration. The effect centers around anovel biologic observation that actin and related cyto-structuresubcellular elements are stimulated by botulinum toxin causingupregulation of cyto architectural protein after injections, causingpreservation of cellular structures through enhancement of thecytoskeleton, preservation of cell internal structures, and enhancementsof adhesions between cells, enhancement of actin production andmicrotubules cross connections between cells which support and enhancebiologic barriers.

Targeted ulcers occur in the colon, skin along extremities and lowerlegs, decubitus ulcers, pressure ulcers, corneal ulcers, mouth andtongue ulcerations, esophageal ulcers, stomach ulcers, poorly healingsurgical and cutaneous wounds, burn induced wounds, ulcers induced byvasculitis, infections by bacteria and fungus, around surgically inducedostea, per rectal ulceration, radiation induced ulcerations, mouth andgingival ulcers, gingival retraction, conjunctival ulcers, and postinfectious ulcers. Injectable and topical methods of delivery areoperational for these injections.

Critical epithelial/endothelial barriers include not only the retinalpigment epithelial barriers, but corneal epithelial integrity, urologicepithelial barriers in urethra and bladder, blood brain barriers,endothelial barriers in blood vessels and corneal endothelium, repair ofendothelial microvilli with the GI tract and enhancement of dentalgingival barriers important in generation of tooth decay and periodontaldisease. The biologic barriers are enhanced by augmentation of the actinand related protein cyto skeleton causing enhancement of barrierintegrity necessary for the health maintenance of the target organ andrelated tissues.

Botulinum toxin has been conventionally used to treat spastic muscles,temporally denervate glands (eccrine and sebaceous glands, salivaryglands, prostate gland, lacrimal gland, mucous secretions from nasalmucosa, acid secretion in stomach. Muscular targets have been to inducemyoneural blockage causing neurogenic muscular atrophy by blockingacetyl choline release by blockage of vascular release of acetylcholine. The targets involve binding of the heavy chain to thepresynaptic membrane via the c-terminus of the botulinum toxin heavychain to the membrane receptor with penetration of the light chain intothe cytoplasm causing cleavage of SNAP-25, a mechano-fusion proteinessential in exocytosis. The blockage of myoneural junctions occurs on adose-dependent area surrounding injections in a fashion that the effectsare targeted to involved area and that undesirable diffusion causingcomplications does not occur. Beyond these applications, botulinum toxinis used herein to produce increased integrity of an epithelial surfaceto enhance to cell to cell integrity of the surface, enhance the barrierfunction of the surface and function to sustain the surface fromdegenerative changes occurring in senescence or in disease processes.

The cellular effect which enhances the applications of botulinum toxinto novel indications which are difficult and often impossible toeffectively and definitively treat. The invention stems from a formerlydescribed “epi phenomena” associated with neuro-muscular injectionblockade. Injections of botulinum toxin causes blockage of exocytosis ofacetyl choline from pre synaptic vesicles, flaccid muscular paralysis,with subsequent atrophy of the muscle cells. The epi phenomena involvessprouting of the nerve around the myoneural block with growth of thesprouts away from the neuromuscular junction. Prior observers haveinterpreted this cellular response was secondary just to the myoneuralblock, however this explanation ignores the observation that this effectis a direct effect of botulinum toxin to enhance actin and related cytoarchitectural protein stimulated directly by the toxin and associatedproteins causing increased protein synthesis and expression of the actinand related cyto architecture which causes the sprouting. Thisobservation is operational to the inventions and clinical applicationsdescribed herein and define a subcellular process by which the toxinproduced benefit to targeted tissues.

Actin and related adhesion and associated protein cyto architecture iscritical for many cell and cellular tissue functions, longevity, andbarrier integrity. Programmed cell death can occur by spontaneouscellular destruction of the cyto skeleton protein and such proteins arecritical to cellular polarity, specialization, and cell adhesion.Upregulation of actin and related proteins in disrupted cell and tissuecause by inflammation, degeneration, infections, metabolic derangements,trauma, or burns helps cells and tissues to resist death anddestruction. This essential effect of botulinum toxins is critical tothe practice of use of botulinum toxin to assist in the healing process,enhancing wound healing, enhancing epithelial healing and the velocityof healing. Cyto skeleton enhancing drugs can be enormously helpful tobe used to preserve cells from destruction based on various causes.

Botulinum Toxin Types (Topical Application and Injection) to achievecytoskeletal changes similar to C2, C3)

Botulinum toxin exists as types A(1-5), B, C, C2, C3, D, E, F, G. Thetoxin type C2,3 cause a cytotoxic effect causing cell death byinfluencing the lysis of actin, increased tissue and cell permeabilityand integrity causing a cytotoxic effect. The other neurotoxins causeorganism death by flaccid paralysis, asphyxiation from respiratoryparalysis. The essential component to this invention involves usingvarious forms of non type C2,C3 toxin to achieve intra cellular andintercellular enhancing effect on actin and related protein productionas a cyto-protective effect of the botulinum use by application at lowerdoses (e.g., various forms of type A toxin). In effect, various formsand doses (concentrations) of botulinum toxin can have opposite effectson the cyto skeleton proteins depending on tissue type and cell cycles.This observation and derivative application is essential tounderstanding the practice of the invention. Type A botulinum toxin byenhancement and preservation of the cyto skeleton can be protective andnot toxic at given dosing and application methods described herein. Thisconcept is counter intuitive to the know effects of certain isoforms ofbotulinum toxin such as type A.

Epithelial Surfaces

Epithelial surfaces tend to have cellular and tissue integrityrequirements important to the health and resilience to various forms ofdiseases and injuries.

The skin and mucous membranes are the apparent epithelial surfaces inthe human body. The skin functions to maintain moisture content in thebody and protect against life threatening dehydration with humidity,temperature, convection changes. The skin involves tightly compactedsquamous epithelial cells important to the function of the biologicbarriers. These cells arise from germinal cells attached tightly to abasement membrane and to each other on a plane that is normal to theepithelial surfaces. Actin and related microtubule structure arestrongly expressed in the cytoplasm of these cells and respond tovarious insults such as burns, viral diseases, trauma, autoimmunediseases, degenerative conditions, and hereditary defects. Thesubcellular elements important to the contribution of the skin as afunctioning barrier include actin and microtubule organization of theskin cell allowing for a high number of adhesions includingtranscellular tubular organization, desmosomes and hemi-desmosomes, andcell membrane integrity. Diseases and genetic experimental modelsinvolving actin and related protein derangements causes a disruption ofthe barrier leading to structural changes, dehydration, protein loss anddamage and structural skin disfigurement.

Herein, an approach is described which alters the actin and relatedmicrotubule elements of the skin cells so that:

-   -   1. The integrity of the skin barrier is maintained by topical or        injectable botulinum toxin so that evaporation, protein leak,        release of proteases enzymes, immuoglobulins, and leukocytes        potentially harmful to the epithelial barrier.    -   2. Enhance epithelial cell integrity and proliferation so that        ulceration and other forms of skin discontinuity can heal more        effectively.    -   3. Function as a preventative therapy to keep wound ulcers from        forming such as cutaneous pressure ulcers, ocular exposure        ulcers from facial paralysis or exophthalmos, esophageal ulcers        with the esophageal mucosa due to reflux, bladder ulceration        from irritates such as radiation or chemo therapy, peptic        ulceration in in patient with active or past duodenal ulcers,        genival retraction from breakdown of gingival epithelium from        bacteria or genetic predisposition.

Mucous membrane surfaces are also subject to ulcerations, anddysfunctions related to loss of barrier integrity. Such loss ofintegrity can lead to leakage of enzymes, immunoglobulins and relatedcellular elements such as polymorphonuclear leukocytes capable offurther damage to barrier functions and other cellular functions of themucous membrane surfaces. Botulinum toxin when applied by injection ortopically can function to enhance the integrity of the mucous membraneepithelial barrier by causing a microtubule alteration in the mucousmembrane cellular structure allowing for increased barrier function ofthe epithelial cells.

Herein, an approach is described which alters the actin and relatedmicrotubule elements of the mucous membranes and intercellular bindingproteins (cadherins) cells so that: (1) the integrity of the skinbarrier is maintained by topical or injectable botulinum toxin so thatevaporation, protein leak, release of proteases enzymes, immuoglobulins,and leukocytes potentially harmful to the epithelial barrier and/or (2)epithelial cell integrity and proliferation are enhanced so thatulceration and other forms of skin discontinuity can heal moreeffectively.

Examples of mucous membrane surfaces applicable include but are notlimited to: Conjunctival, Vaginal, Rectal, Alveolar, Glomerular andrenal tubules, Intestinal, Gastric, Esophageoal, Nasal Mucosa, Oralmucosa, Dental-Gingival mucosa (periodontal disease), Bronchiolar andtracheal mucosa, Bladder mucosa, Urethral mucosa, Ureter Mucosa, and/orGall Bladder and biliary duct mucosa.

Conventionally, botulinum toxin is used to removed dynamic lines andwrinkles based on a neuromuscular weakening effect. This approach hasbeen employed for decades and is the source of billion-dollar revenuemarket. This approach also has been the target for United States FDAapproval pathways for these indications using forced frown lines as anendpoint. Muscle injections are described as the target for injection toproduce the favorable aesthetic results.

The disclosed formulations and therapeutic methods may, in some cases,tighten the cell to cell adhesions in epithelial surfaces provide moreinsight and utility to aesthetic application. Application of botulinumtoxin by injection to non-muscular regions at multiple puncture sites onsurfaces away from muscle tissue can prove beneficial to skin textureand be effective in removing non-dynamic wrinkles (wrinkles notgenerated by resting muscle tone or contractions of muscles). Thedisclosed formulations may be delivered along multiple punctures sitesfar lower than necessary to produce a muscle weakening effect.

Botulinum Toxin Action on the Rho Protein Family

Certain immune-types of botulinum toxin are known to act as cytotoxinscausing cell damage and poisoning by non-neuromuscular mechanisms. Theseare the botulinum C2,C3 types which are distinctive both in chemistryand cellular effect. These toxins are known to enhance actin dissolutionby actin and disruption of tight junctions with vascular leakage,hemodynamic instability and death. This toxin act as ADP ribosylatingtoxin which interfere with actin formation and integrity. Recently,botulinum toxin type A has been shown to interfere which fibroblastmigration and function and reduce cutaneous scars. The observationsindicate by observers that other botulinum toxins have an effect onactin cytoskeleton elements in a way that impairs actin formation andcellular functions associated with actin such as cell motility, andtissue functional integrity. These biologic effects are negative whentoxin is given at high doses to cause impairment of cellular function.

Cell motility requires actin cell polymerization and dissolutionoccurring rapidly to accomplish this function from member of the Rhoprotein family (Cdc2, Rac, Rho). These proteins are also involved in themaintenance of cell polarity, motility, important to many tissue barrierfunctions.

Contrary to the above, the invention described herein involves apositive effect on barrier cells to enhance and strengthen cell to cellcontact and cell to basement membrane contacts for non-motile epithelialcells constituting a biologic barrier as well as enhancing (notdepressing) cell migration when a defect is present or enhancingbiologic barriers important to disease processes when there is a defectin epithelial adhesion and transformation. Improvement in barrierdysfunction results from the cyto architectural effect from the toxin.The type A botulinum toxin has been associated with reorganization ofactin fibers in neural derived cell cultures indicating a contraryeffect to related type C2,C3 and type D toxin. Rather than disrupt cellto cell contacts, type A toxin is able to cause actin and relatedproteins to reorganize the cytoskeleton in a configuration that tightenscell to cell contact, increase integrity of biologic barriers, enhancefunction of epithelial barriers and promote epithelial and endothelialgrowth ton seal defects in endothelial and epithelial cell barriers. Themechanism can relate to interacting to similar enzymes in the Rho familyadjusting relative rates of actin and related protein reorganization tothat the tight junctions are enhanced and biologic interactions of actinwith its attachment protein cadherin and specialized cell intermediatefilaments enhance cell function and barrier functions.

The above appears contrary to published reports but just as theneuromuscular effects are controlled by dose. These cytological effectsare also subject to doses conventionally used to treat medicalconditions described herein. Such doses can modulate the actin skeletonin a way to enhance the barriers and cellular adhesive qualityincreasing the function within the epithelial barrier to mitigate adisease process based on a subliminal effect on the cyto skeleton withenhancements of adhesion from actin, cadherin interactions.

Complex Vs Pure Neurotoxin

Current efforts in pharmaceutical design have sought to remove theaccessory protein from botulinum toxin preparations. These proteinsinclude hemagglutinin and non-hemagglutinin non-neurotoxin proteins.Recently, botulinum-associated protein hemagglutinin has been associatedwith interaction and weakening of cadherin proteins in tissue types.Cadherin interactions can be important in maintaining the integrity ofthe neural synapse. This disruption is tight to further disrupt theactin cell element of the presynaptic neuron and provide for an enhanceof botulinum toxin uptake at the presynaptic structure causing a moreeffective penetration of botulinum toxin uptake enhancing the potencyand effectiveness of the injectable or topically applied botulinumformulation. The interaction with cadherin protein can trigger genomicresponse causing enhanced cadherin and associated proteins for cell andtissue repair.

The effectiveness of some formulations of botulinum toxin have beenobserved by clinicians not to be equivalent to botulinum complex (BOTOX®vs XEOMEN). Any membrane interactive substance which can increasepermeability of botulinum toxin into the neuron may be useful to enhancepotency. Recently, two studies on rhytids and adult onset spasmodictorticollis) which reported increased potency based on an adjuvantpoly-lysine (poly-cation) which was designed to increase penetration tothe motor neuron axon tip. Alternate methods are described herein ofincreasing the concentration of the hemagglutinin to enhance effect ofthe formulation on muscle to axon nerve tip intercellular attachmentprotein in such a way to increase permeation of the neuron to the axontip and enhance potency.

Prophylactic Therapy in Stage 1 Macular Degeneration

The therapies disclosed herein, in some embodiments, include benignplacement alternatives to intra-vitreal injections which represents thecurrent placement method in using anti-VEGF pharmaceuticals such asEylea®, Lucentis®, and Avastin®. In some embodiments, the disclosedmethods provide an opportunity for a novel treatment approach ofproviding a prophylactic therapy for high risk patients, patientsdiagnosed with stage 1 AMD, and/or patients with high risk features toprogress to geographic atrophy or stage 2 (exudative) AMD.

In current practice, macular degeneration is often diagnosed as stage 1before the disease progresses to the rapid vision-destroying stage 2degeneration involving intra-retinal and sub-retinal leakage from newvessels growth and new vessel growth under or over the retinal pigmentepithelium. In some embodiments, a method of preventing any stage ofmacular degeneration is provided that involves: identifying a patientwith high risk for AMD based on genomic testing for high riskpolymorphisms genes structures noted to be associated with maculardegeneration. In these and other embodiments, the method continues withproviding an extra-ocular injection in the orbit, Para orbital, periorbital region (sinuses or temporal), and/or pterygopalatine fossalateral orbital region, in a manner that allow botulinum effect on theposterior eye, macular or intra-ocular structures. The method maycontinue with monitoring the patient and eventually decreasing theincidence of macular degeneration on the targeted eye or eyes using themethods as described herein for macular degeneration assessment.

There are risk factors for the development and progression of AMD thatmay be used in connection with the disclosed methods. For example,possible risk factors that may be considered include but are not limitedto: number and volume of drusen and drusenoid lesions, extent andposition of geographic atrophy in target or contralateral eye, numberand position of hyper-reflective foci into the neuroretina (eitherposition over drusen-drusenoids), loss and disorganization of continuityof IS-OS line or outer nuclear layer, hyper or hypo pigmentation,hyper-reflectivity and deposits within the drusens, dynamic changes innumber and size of drusens, soft drusen, hyperreflective foci, IS-OSlines ONL, and presence and number of pseudo-drusen. Additionally,genetic testing may be employed in connection with the disclosed methodsto assess polymorphisms associated with severe macular degeneration aswell as complement factors and other genes associated with severedisease.

Macular Edema

There are many known causes of macular edema. For example, macular edemais frequently associated with diabetes, where damaged blood vessels inthe retina begin to leak fluids, including small amounts of blood, intothe retina. This is the most common cause of visual loss associated withdiabetes. Sometimes deposits of fats may also leak inside the retina.This leakage causes the macula to swell. In this situation, the biologicbarrier is defined by the retino-vascular endothelium and supportingpericytes in the retinal circulation.

Eye surgery, including cataract surgery, can increase your risk ofdeveloping macular edema due to blood vessels becoming irritated andleaking fluids. Macular edema that develops after cataract surgery iscalled cystoid macular edema (CME). Some of the other macular edemacauses include: type 1 and type 2 diabetes, age-related maculardegeneration (AMD), uveitis, retinal vein occlusion (branch and centralretinal vein occlusion—Example 8), blockage in the small veins of theretina, due to radiation, macular telangiectasias, side effects ofcertain medications, and certain genetic disorders, such asretinoschisis or retinitis pigmentosa, incontinea pigmenti. Thedisclosed formulations are methods may be used to treat, prevent, orcure macular edema caused by one or more of these conditions.

By mechanisms described herein, the barrier occurring around the retinalvessels (endothelium and peri-cytes) can be augmented causing less leak,less macular edema, and/or preservation of vision. For theseindications, injections can be given via pars plana (intra-ocularinjections) or through soft tissue injections surrounding the eye in asimilar manner described for macular degeneration. Topical applicationswith higher doses used to achieve greater penetration can also be used.Such higher doses are within the ranges from 1-5,000 units.

Renal Function (Barrier Function) and Nephrotic Syndrome

Nephrotic-range proteinuria is the loss of 3 grams or more per day ofprotein into the urine or on a single spot urine or on a single spoturine collection, the presence of 2 g of protein per gram of urinecreatinine. Nephrotic syndrome is the combination of nephrotic-rangeproteinuria with a low serum albumin level and edema. Nephrotic syndromehas many causes, including primary kidney diseases such asminimal-change nephropathy, focal glomerulosclerosis, and membranousnephropathy. Nephrotic syndrome can also result from systemic diseasesthat affect other organs in addition to the kidneys, such as diabetes,amyloidosis, and lupus erythematosus. Nephrotic syndrome may affectadults and children of both sexes and of any race. It may occur intypical form, or in association with nephritic syndrome. The latterconnotes glomerular inflammation, with hematuria and impaired kidneyfunction.

Nephrotic syndrome can be primary, being a disease specific to thekidneys, or it can be secondary, being a renal manifestation of asystemic general illness. In many cases, injury to glomeruli is anessential feature. Kidney diseases that affect tubules and interstitium,such as interstitial nephritis, will not cause nephrotic syndrome.

Primary causes of nephrotic syndrome include the following, inapproximate order of frequency: Minimal-change nephropathy, Focalglomerulosclerosis, Membranous nephropathy, and Hereditarynephropathies. Secondary causes include the following, in order ofapproximate frequency: Diabetes mellitus, Lupus erythematosus, Viralinfections (e.g., hepatitis B, hepatitis C, human immunodeficiency virus[HIV]), Amyloidosis and paraproteinemias, Preeclampsia, andAllo-antibodies from enzyme replacement therapy.

Nephrotic-range proteinuria may occur in other kidney diseases, such asIgA nephropathy. In that common glomerular disease, one third ofpatients may have nephrotic-range proteinuria. Nephrotic syndrome mayoccur in persons with sickle cell disease and evolve to renal failure.Membranous nephropathy may complicate bone marrow transplantation, inassociation with graft versus host disease. From a therapeuticperspective, nephrotic syndrome may be classified as steroid sensitive,steroid resistant, steroid dependent, or frequently relapsing.

In a healthy individual, less than 0.1% of plasma albumin may traversethe glomerular filtration barrier. Controversy exists regarding thesieving of albumin across the glomerular permeability barrier. On thebasis of studies in experimental animals, it has been proposed thatongoing albumin passage into the urine occurs in many grams per day,with equivalent substantial tubular uptake of albumin, the result beingthat the urine contains 80 mg or less of albumin per day.

However, studies of humans with tubular transport defects suggest thatthe glomerular urinary space albumin concentration is approximately 3.5mg/L. At this concentration, and a normal daily glomerular filtrationrate (GFR) of 150 liters, one would expect at most 525 mg per day ofalbumin in the final urine. In health, urine albumin is less than 50mg/day, because most of the filtered albumin is re-absorbed by thetubules. Amounts above 500 mg/day typically point to glomerular disease.

The glomerular capillaries are lined by a fenestrated endothelium thatsits on the glomerular basement membrane, which in turn is covered byglomerular epithelium, or podocytes, which envelops the capillaries withcellular extensions called foot processes. In between the foot processesare the filtration slits. These three structures—the fenestratedendothelium, glomerular basement membrane, and glomerular epithelium—arethe glomerular filtration barrier. A schematic drawing of the glomerularbarrier is provided in FIG. 8.

FIG. 8 shows a schematic drawing of the glomerular barrier. In FIG. 8,the abbreviation “GBM” refers to the glomerular basement membrane and“ESL” refers to the endothelial cell surface layer (often referred to asthe glycocalyx). Primary urine is formed through the filtration ofplasma fluid across the glomerular barrier (arrows); in humans, theglomerular filtration rate (GFR) is 125 mL/min. The plasma flow rate(Qp) is close to 700 mL/min, with the filtration fraction being 20%. Theconcentration of albumin in serum is generally 40 g/L, while theestimated concentration of albumin in primary urine is 4 mg/L, or 0.1%of its concentration in plasma.

Filtration of plasma water and solutes is extracellular and occursthrough the endothelial fenestrae and filtration slits. The importanceof the podocytes and the filtration slits is shown by genetic diseases.In congenital nephrotic syndrome of the Finnish type, the gene fornephrin, a protein of the filtration slit, is mutated, leading tonephrotic syndrome in infancy. Similarly, podocin, a protein of thepodocytes, may be abnormal in a number of children withsteroid-resistant focal glomerulosclerosis.

The glomerular structural changes that may cause proteinuria are damageto the endothelial surface, the glomerular basement membrane, or thepodocytes. One or more of these mechanisms may be seen in any one typeof nephrotic syndrome. Albuminuria alone may occur or, with greaterinjury, leakage of all plasma proteins (ie, proteinuria) may take place.Proteinuria that is more than 85% albumin is selective proteinuria.Albumin has a net negative charge, and it is proposed that loss ofglomerular membrane negative charges could be important in causingalbuminuria. Nonselective proteinuria, being a glomerular leakage of allplasma proteins, would not involve changes in glomerular net charge butrather a generalized defect in permeability. This construct does notpermit clear-cut separation of causes of proteinuria, except inminimal-change nephropathy, in which proteinuria is selective.

The renal tubules are also governed by barrier function in the cell tocell adhesion and attachments to basement membranes. Targeting thekidney or nerves entering the kidney can be useful to treat renaldiseases in which barrier function are essential.

As botulinum toxin is capable of stimulating proteins which areessential to cells to cell adhesion and attachments to basementmembranes, the enhancement of the adhesion complexes at the glomerularbarrier and tubules can be useful to treat kidney disease. The kidneylies in the retro-peritoneum close to the mid to lower back making thisorgan assessable to injections through back muscles, and organ viainnervation with axoplasmic transport. Needle can access the kidney fromback injections and diffusion through dosing nomograms. In some cases,the treatment objective may be to slow progression on diabetic need fordialysis or to treat or prophylactically treat glomerular disease withhigh risk patients (for example, advanced stage diabetics, system lupuspatients, para-proteinemias, patients with systemic amyloidosis, orprimary nephrotic syndromes).

Periodontal Disease Tooth Loss

Teeth are attached to the surrounding and supporting alveolar bone byperiodontal ligament (PDL) fibers. PDL fibers run from the bone into thecementum that naturally exists on the entire root surface of teeth. Theyare also attached to the gingival (gum) tissue that covers the alveolarbone by an attachment apparatus. Because this attachment existssuperficial to the crest, or height, of the alveolar bone, it is termedthe supracrestal attachment apparatus. This apparatus is subject todeterioration in Periodontal disease.

The supracrestal attachment apparatus is composed of two layers: thecoronal junctional epithelium and the more apical gingival connectivetissue fibers. The two layers together form the thickness of thegingival tissue and this dimension is termed the biologic width.Plaque-induced periodontal diseases are generally classified destructiveor non-destructive. Clinical attachment loss is a sign of destructive(physiologically irreversible) periodontal disease. The quality of theepithelial layers define the extent and progression of periodontaldisease.

The barrier function of the epithelial layers helps prevent and retardperiodontal disease. Repeated use of botulinum toxin by topicalapplication, regional injection can cause a tighter seal fromaugmentation of cell to cell adhesion protecting the quality of boneloss and PDL integrity. In gingivitis, inflammation localized to thesupracrestal region of the periodontium leads to ulceration of thejunctional epithelium. Although this is technically a loss of clinicalattachment, the term clinical attachment loss is used almost exclusivelyto refer to connective tissue attachment loss. Use of repeated botulinuminjections can result in prevention and therapy of ulceration,epithelial erosion, with subsequent loss of PDL integrity, connectivetissue attachment and loss of bone.

Example 1—Exudative (Wet) Macular Degeneration not Responsive toConventional Therapy

A 71 year old man was diagnosed with progressive macular degenerationwith substantial sub retinal and sub foveal fluid, which wasunresponsive to repeated Avastin® intra-vitreal injections and EyleaIntra vitreal injections (10 injections)(FIG. 9A-9E). Patient wastreated with 100 units of per-ocular botulinum toxin type A (BOTOX®) inforehead, orbicularis and deep temporal fossa which resulted in asubstantially augmented response to an anti-VEGF agent on subsequentinjection with substantial resolution of sub foveal fluid (see FIG.9A-9E).

The patient noted his vision was augmented after the combination ofanti-VEGF and botulinum formula than the prior unsuccessful Anti-VEGFtherapy. The interpretation was that the botulinum toxin given beforethe next anti-VEGF enhanced the response and converted this patient wetmacular degeneration to a dry state (due to the antecedent botulinumtoxin injections).

Anatomic improvement in this patient included flattening of the retinaas documented with ocular coherence tomography, decrease in sub-retinaland intra retinal fluid, decreased choroidal neovascular membrane, andthickening of the RPE (FIG. 9F). These anatomic findings are typical forpositive response to exudative (WET) age related macular degeneration.

Example 2—Non-Exudative Macular Degeneration (Dry Macular Degeneration)

The results of this example are shown in FIGS. 10A and 10B. Elderlyfemale with well-documented non-exudative macular degeneration in eacheye and about 20/40 vision in each right and left eye receives botulinuminjection comprising about a total of 100 unit to head, per-orbitalregion and an area into the pterygopalatine fossa targeting theautonomic and sensory ganglionic structures in this region. The patientnotices slow improvement in contrast sensitivity and clarity of vision,which lasted about three months. She desired another injection with thetype A botulinum toxin (BOTOX-A®, Allergan) in order to maintain vision.On ophthalmologic exam no other reasons for the subjective improvementin vision could be established on pre-injection and post injectionexaminations.

Optical coherence tomography indicates flattening and regression ofdrusen bodies as well as increased surface regularity of the retinalpigment epithelium (FIG. 10). Findings were concomitant with subjectivevisual improvement.

Without wishing to be bound by theory it is believed that the injectionsin peri orbital nervous structures allowed for axoplasmic transport intothe eye improving functioning of the retinal pigment epithelium functionand possibly structure allowing improved vision.

Example 3—Filamentary Keratitis (Improvement of Corneal EpithelialIntegrity and Adhesion Based on Direct Surface Examination of anEpithelial Sheet)

A 71-year-old man was treated for blepharospasm for 10 years. He notedimprovement after injections ranging from 40-80 units. Concomitantly, hewas diagnosed to have filamentary keratitis. After botulinumadministration by drop form (20 units) and by injection into lids, thefilaments disappeared or were markedly improved associated withdecreased light sensitivity, decreased pain, improved vision, andincreased regularity of the epithelium, as demonstrated by computerizedreflective corneal topography. The increased adhesiveness of theepithelium resulted in improvement in his corneal surface with improvedvision, reduced surface distortion and lessened pain with concomitantresolution of detached filaments.

Example 4

An 82-year-old woman with long standing stage 1 macular degeneration hadbeen followed for stage 1 macular degeneration for about 4 years. Shenoted some decrease in vision in the left eye over one year. OCT (Zeiss)showed accumulation of intra-retinal fluid over degenerated retinalpigment epithelium as a change from a previous scan (see FIGS. 11A-11D).Previous scan showed dry degeneration with irregularity in sheetconfiguration of the RPE with evidence of RPE discontinuity and breakupwith neural retinal RPE migration (focal hyper reflective lesions movinginto neuroretina) (FIG. 11A).

Injection of botulinum toxin after advice to patient of side effects wasmade using 70 units under the temporal muscle in several locations andin peri-orbital region (multiple dose injection). Region of thepterygopalatine fossa was also targeted for diffusion effect. FIG. 11Bshows peri-foveal leakage with conversion of the macular degeneration towet variety.

The plan for treatment with Avastin® or Eylea® was made within 2 weeks.Sub muscular injection toward the pterygopalatine fossa was made with 70IU of botulinum toxin type A. Repeat OCT san after 10 days showed noresolution of fluid (FIG. 11C). After 14 days there was completeresolution of the fluid (see FIG. 11D).

This case demonstrated the tempo of effect required about 14 daysconsistent with a delay expected with axoplasmic flow. This casedemonstrated converting stage 2 macular degeneration (wet variety) tostage 1. No intra ocular injection with Eylea® or Avastin® was necessaryand intra-ocular injections were aborted. The patient was referred forcontinued monitoring.

Example 5

An 87-year-old woman with 20 years of hem-facial spasm. She developeddry macular degeneration 4 years prior. About 2 years after sheconverted to wet degeneration with leaks into the sub retinal space andneuro-retina, several injections of Avastin® resulted in drying of theneuroretina with improvement in vision. She remained stable for abouttwo years when a routine OCT exam revealed re-accumulation of fluid inthe peri foveal region. A botulinum toxin injection was given for herhemi facial spasm in doses routine for this condition. Additionally, adeep injection of 20-30 unit was directed toward the pterygopalatinefossa directed at nerve ganglion. Her pre-injection photo is shown inFIG. 12A.

After two weeks improvement in perifoveal fluid was noted to occur (FIG.12B). Vision improved in the left eye from 20/40 to 20/25. Note thefluid accumulation on both sides of the fovea is substantial mitigatedafter two weeks. Further, increase structural regularity (surfacesmoothness of RPE is enhanced, black and white, and external limitingmembrane and IS-OS interface are more defined). At 10 weeks, knowduration end for botulinum toxin and fluid accumulation begins to recur.Repeat injections after re accumulation of fluid in 10 weeks resulted ina second cycle response with complete resolution of intra-retinal edema.Dosing injections were increased to 100 units.

Example 6—Macular Edema

A 90-year-old man with a 35-year history of type 2 diabetes presentswith macular edema 5 years after cataract surgery. Microaneurysms/leakage are documented in the macular by inspection andangiography. Macular edema is documented by OCT. 40 U of botulinum typeA toxin is injected in region of pterygo palatine fossa outside the eyeand eye socket. After 3 weeks there is complete resolution of macularedema. The experimental results of this example are provided in FIGS.13A and 13B. In particular, FIG. 13A illustrates the macular edema priorto injection and FIG. 13B illustrates the macular edema symptomreduction visible 3 weeks after temporal injection toward thepterygo-palatine fossa (with spatial computer registration). Repeatinjections are planned.

Example 7—Retrospective Review

After initial observation (Example 1), a retrospective review of severalhundred records of general eye patients treated for types blepharospasmand cervical dystonia (treated with botulinum toxin), diseases in olderage groups, was conducted for progressive age related maculardegeneration. No patient had a macular degeneration progression whileunder repeated botulinum injections. The absence of this common problemin patients over the age of 60 was unusual and suggests cause effectwith concomitant botulinum treatment. Dosing ranges for these patientswas typically between 10 and 600 units.

Example 8—Central Vein Occlusion

An 84-year-old woman with central vein occlusion OD who, for othermedical reasons, could not receive anti-VEGF therapy for a period of 5months, presented with extreme macular edema and hand motions vision. 50Units of botulinum toxin was injected on the involved side. After 2weeks the macular edema was reduced by 60-70% on SD OCT with some visualimprovement (CF 3 ft) in the involved eye. Repeat dosing of 100 unitswas given to the patient. Vision slowly improved to 20/800 in theinvolved eye. Botulinum toxin with anti-VEGF (Avastin™) improved to20/100.

An added extended botulinum toxin injection in para-orbital regionsmaintained the macular with CRVO-related edema for a period of 10 monthswithout recurrence. This example case indicated additive effects ofbotulinum toxin with respect to potency and duration of action ofconventional therapy with Avastin™.

Example 9

An 86-year-old light skin male presented with evidence of early drusenin both macular regions and notices a small decline in vision to 20/30(minus 2) OD and 30/30 (minus 1) OS. OCT-A images of the patient's eyesafter treatment are shown in FIGS. 15A and 15B (FIG. 15A illustrates theleft eye and FIG. 15B illustrates the right eye). The OCT-A images shownin FIGS. 15A and 15B were obtained using a Spectral domain (5000 Zeiss)and show sub-foveal choriocapillaris and defective flow in sub fovealchoriocapillaris in both eyes. This patient received botulinum toxininjections into the para orbital region directed into thepterygopalatine fossa at a single dose of 25 units (BOTOX® units) oneach side. After the botulinum toxin injections, the patient experiencedan improvement in vision in both eyes.

FIGS. 15A and 15B show increased capillary flow (choroidal blood flow)under the fovea after three weeks on both the right and left side. Notethe increase in density of the signal and the fill in of thechoriocapillaris.

Example 10

An 83-year-old woman presented with peri foveal geographic atrophy inthe left eye and moderate dry macular degeneration in the right eye.After an injection of 60 units on the left side (with severe geographicatrophy) and an injection of 15 units on the right side (moderate dryAMD) she experienced the following changes in vision: the side with perifoveal geographic atrophy has clearer vision around the blind spot thanpreviously. She described the vision around the corresponding scotoma(blind spot) was even better than the right eye. Without wishing to bebound by theory, the difference in botulinum toxin dose provided to therespective eyes may have affected the type of results experienced. Inother words, the dose of 60 units may have a greater effect on thepatient than the dose of 15 units.

A photograph of the patient's eye obtained using OCT-A techniques threeweeks after treatment is shown in FIG. 16. FIG. 16 shows improvement inthe choroidal choriocapillaris perfusion. In particular, the increase inflow denoted by contrast within the peri foveal region in the choroidand the increase in choriocapillaris signal in the region can be seen inFIG. 16.

Example 11

An 81-year-old man with a history of exudative macular degeneration forpast six years was treated as follows. Repetitive Avastin™ injectionswere given in both eyes which resulted in a dry macula state for 4 yearswith visual acuity of better than 40/40 OD, 20/40 OS. A focal area “T”with fluid accumulation occurred over the past two years which slowlyincreased in size. The cyst was located in the peri foveal, which seemedto start causing a decrease in vision in the left eye.

An injection of botulinum toxin directed into the pterygopalatine fossawas administered on both sides after informed consent was provided.After treatment, the patient's vision improved in both eyes. The focalfluid in the left eye shrunk after three weeks (see FIG. 17A). The cystslowly recurred after 8 weeks. Another trial injection was made notinvolving conjunctival, or orbit regions. The cyst again shrunk forabout 8 weeks. Another trial of botulinum A toxin was injected into thepara orbital region again causing shrinkage of the cyst. OCT-A imagesdemonstrated improvement in blood flow after the pterygopalatineinjections.

Note that this case demonstrated an improvement in perifoveal fluidaccumulation with repeated effectiveness. Further, the duration ofeffect was consistent with the known duration of effect of botulinumtype A toxin on multiple cycles, thus adding to the credibility andreproducibility of the observations. The patient noted improvement invision from 20/40 to 20/25 coincident with the structural improvement inthe fovea in his left eye. Further blood flow improvement wasdemonstrated using OCT-A in the region of the foveal fluid,demonstrating an increased clearance at least in part effected by theuveal scleral pump improvement provided by botulinum toxin. Inparticular, the botulinum toxin injected appears to have induced anincrease in blood flow (see FIG. 17A). That is, greater flow appears tohave caused an increase in fluid clearance from the neuro-retina. FIG.17B illustrates an exemplary pterygopalatine injection.

Example 12

A 73-year-old man presented with a history of high myopia, latticeretinal dystrophy, a history of retinal detachment, and dislocated IOLdue to zonular dehiscence. The patient may also have Marfans syndrome.An anterior chamber lens was implanted with subsequent development ofmacular edema associated with epiretinal membrane formation. The patientrefused intraocular injections of Eylea and was alternatively givenpara-orbital injections of botulinum toxin. Topical steroid failed toimprove the macular edema. Steroids and botulinum toxin administered viapara-orbital injections produced substantial improvement in the macularedema (see FIG. 18A). Further, increased blood flow to the choroid wasdemonstrated 2 weeks after paraorbital botulinum toxin was injected (seeFIG. 18B). Note that the effectiveness of the uveal scleral pump wasused to dry the macula in this complex case by para orbital injections.

FIG. 18C illustrates an exemplary uveal sclera pump in which the choroidacts as a flow generated suction pump bringing fluids out of the eye.The integrity of the Bruch's membrane and retinal pigment epithelialbarrier is dependent on the pump. A defect in pumping contributesgreatly to macular degeneration. Note the circular orientation of thechoroidal vortex venous system shown in FIG. 18C in an additionorientation to increase flow dynamic in the choroid under the RPE.Defects in the RPE and Bruch's membrane can cause leaks in the pumpingsystem, leading to fluid accumulation. FIG. 18D is an image showingfeatures of an exemplary eye.

Selected Example Embodiments

In some embodiments, a method of preventing and slowing the developmentof macular degeneration is provided. In some such embodiments, themethod comprises administering a formulation comprising botulinumneurotoxin, a fragment thereof, and/or a neurotoxin associated proteinto a human or mammalian patient suffering from or at risk for losingvision from macular degeneration. In these and other embodiments, thebotulinum neurotoxin, fragment thereof, and/or neurotoxin associatedprotein is selected from the group consisting of: botulinum toxin A1-A5,B, C1-3, D, E, F, G and H.

In another example embodiment, a method of enhancing activity ofanti-VEGF injectable agents is provided. In some such embodiments, themethod comprises administering a formulation comprising a botulinumneurotoxin, a fragment thereof, and/or a neurotoxin associated proteinto a patient suffering from exudative forms of macular degeneration,wherein the formulation is administered to the patient via intra-ocularinjection or extra ocular injection and administering an anti-VEGF agentto the patient. In select embodiments, the formulation comprises afusion protein containing botulinum neurotoxin or a fragment thereof andthe anti-VEGF agent. In these and other embodiments, the formulation isadministered to the patient separately from the anti-VEGF agent. Incertain cases, the anti-VEGF agent is selected from the group consistingof: a ranibizumab, a bevacizumab, and an aflibercept.

In other embodiments, a method of diminishing progressive visual lossfrom retinitis pigmentosa is provided. The method may comprise, in somecases, administering a formulation comprising a botulinum toxin or afragment thereof to a patient suffering from retinitis pigmentosa,wherein the formulation is administered to the patient via intra-ocularinjection or extra ocular injection.

In other embodiments, a method of diminishing visual loss from diabeticmacular edema from diabetes, central or branch vein occlusion,degenerative retinal disease, retinitis pigmentosa (RP) retinal disease,or uveitis is disclosed. The method may include, in some cases,administering a formulation comprising a botulinum toxin or a fragmentthereof to a patient suffering from macular edema from diabetes, branchvein occlusion or uveitis, wherein the formulation is administered tothe patient via intra-ocular injection or extra ocular injection.

In select embodiments, a method of preventing age-related maculardegeneration in a patient is described. The method may includeadministering a formulation comprising a botulinum toxin or a fragmentthereof to the patient, wherein the formulation is administered to thepatient via intra-ocular injection or extra ocular injection. In theseand other embodiments, the patient may be at risk for maculardegeneration as determined by medical history or genetic evaluation.

A method of treating periodontal disease and tooth loss in a patient isalso described herein. The disclosed method includes administering aformulation comprising a botulinum toxin or a fragment thereof to thepatient, wherein the formulation is injected or topically applied togingiva, peripheral nerves, oral mucosa, or skin in a facial orperi-oral region.

In another example embodiment, a method of treating chronic nephroticsyndrome in a patient is described. The disclosed method includesadministering a formulation comprising a botulinum toxin or a fragmentthereof to the patient, wherein the formulation is injected or topicallyapplied to a kidney or surrounding regions, including one or more nervesentering the kidney. Numerous other example embodiments will be apparentto those skilled in the art upon consideration of the subjectdisclosure.

Definitions and Abbreviations

Unless otherwise defined herein, the following terms have the stateddefinitions.

AMD—age related macular degeneration.

VEGF—vascular endothelial growth factor. VEGF binds to two members of areceptor tyrosine kinase family, VEGF receptor (VEGFR)-1 and VEGFR-2.VEGFR-2 is considered the main VEGF receptor and mediates theproliferative effects of VEGF on vascular endothelial cells. VEGFbinding to VEGFR-2 induces the dimerization and subsequentautophosphorylation of receptors by intracellular kinase domains, whichleads to a mitogenic and proliferative signal. VEGF-C and VEGF-D bind toVEGFR-3, another member of this family of receptor tyrosine kinases.

Botulinum toxin—any immunotype, fraction of botulinum, subtype, derivedfrom C botulinum species by fermentation or genetic expression inrecombinant system.

HA—hemagglutinin derived from production of Clostridia botulinum infermentation or other natural process, or recombinant, or any otherexpression systems (accessory protein).

RPE—retinal pigment epithelium in a mammal. HA is also a botulinumaccessory protein.

OCT—Spectral domain, or any other version or enhancement of ocularcoherence tomography. OCT angiography (OCT-A) is a type of OCT imagingtechnique. Specifically, OCT-A is an imaging technique in which imagingof red blood cell movement in the retinal and choroidal vessels occurs,reflecting blood flow and blood flow rates.

NHNT—Non-neurotoxin, non-hemagglutinin protein produced by fermentationof C botulinum or by recombinant production. NHNT is also an accessoryprotein.

Anti-VEGF—any known VEGF monoclonal or fusion protein, or VEGF agentwhich suppresses angiogenesis and/or leakage. Anti-VEGF terms usedherein refers to an agent which recognized multiple isoforms of VEGF.Agents may include pieces of the VEGF receptors or entire receptorstructures.

Complement protein—any complement factor involved in complementactivation cascade.

Injection—administration of botulinum toxin (and other compounds, ifapplicable) with any form of a needed or microneedle.

Blepharospasm—condition treated with peri-ocular administration ofbotulinum toxin (commonly with a dosing range of between 10 and 300units).

Neuropeptide—any know neuropeptide including but not limited toSubstance P, CGRP, VIP.

ELM—external limiting membrane of the retina.

IS/OS—line defining the inner and outer segments of photoreceptors.

Stress fiber—condensation of contractile actin and associated proteinswhich distorts cell membranes and disrupted barrier effect in a giventissue or epithelial layer.

CRVO—central retinal veins occlusion.

BRVO—branch retinal vein occlusion.

nAMD—stage 2, 3 AMD with neovascularization (active angiogenesis stageswith leakage).

Biologic barrier—any biologic barrier depending on cell to cell adhesionand cell to basement membrane adhesion to maintain tissue function.

mRNA—messenger RNA.

Conventional dosing—any FDA-approved dosing of botulinum toxin for anindication of the head or neck.

Formulation—as used herein, the term ‘formulation’ refers to acomposition of one or more biologic agents with or without excipientpresent.

Fusion protein—addition of one or more proteins produced industriallyfor the purpose of preserving the biologic activity of each protein toenhance the utility of the composition. Generally, the fusion proteinrepresents ligated genes or gene fragments fusion and expressed inappropriate cell system often using PCR to enhance quantity of the genespresent for the expression system.

Macromolecule—a large molecule having a relatively large molecularweight, such as a nucleic acid, protein, carbohydrate, or lipid.

Activity—the term “activity” refers to the specific activity or biologicactivity of a given compound as measured using conventional,industry-accepted methods. The activity of a compound is used toquantify purity or concentration and is calculated as units per mass.

Rho—Rho family GTPase.

Ras—related C3 botulinum toxin substrate ing epithelial differentiation,cytoskeletal reorganization, cell growth.

Ras 2—protein involved in cyto skeletal reorganization.

Ras 3—protein involved intercellular signaling pathways.

ROCK1 protean kinase regulator of actomycin cytoskeleton promotescontractile force generation, important in angiogenesis, cell motility.Major downstream effector of RhoA.

IU—Botulinum LD 50 for 20-30 gm Swiss Webster mouse, “Mouse unit.”

HcA—Fragment of botulinum type A heavy chain serving as binding domainto nerve cells.

SNAP-25—Synaptoso all-associated protein 25 is a component of thetrans-SNARE complex, which is proposed to account for the specificity ofmembrane fusion and to directly execute fusion by forming a tightcomplex that brings the synaptic vesicle and plasma membranes together.Substrate for L chain botulinum activity.

Regular hexagon—six-sided closed figure with equal sides.

Ophthalmologist—A medical doctor trained to treat medical and surgicaldiseases of the eye. Duties include injecting the globe and periocularregion.

EMT—epithelium mesenchymal cell transformation.

GA—geographic atrophy (end stage form of dry AMD).

RPE atrophy—shrinking, flattening and loss of vital physiology of theretinal pigment epithelium.

CNV—choroidal angiogenesis (neovascularization protein to leak fluid andhemorrhage. Occurs under the RPE, under retina and intra neuroretina.

Leakage—abnormal and pathological movement of fluid through a biologicbarriers into intra-ocular structures. The term “leakage” is used hereinto refer to fluid accumulation in the neuroretina, subretina space, orchoroid (sub RPE). Such leakage is commonly associated with distortionof vision and obstruction of photoreceptors.

Uveoscleral pump—a pumping mechanism generated by blood flow into thechoriocapillaris, which produces a low-pressure cell in the region ofthe internal choroid, thereby providing pressure for the attachment ofRPE to Bruch's membrane, suction force removing waste metabolites fromthe neuroretina and internal eye, and a mechanism for removal ofphysiologic fluid in the neuro-retina as well pathologic edema indisease states. The pump keeps the alignment of RPE cells maintainingbarrier function, facilitating RPE phagocytosis, and treatingpathological edema. Defects in the pumping mechanism may be related incause to early and late stages of macular degeneration.

Laser Doppler technique—another method of determining choroidal bloodflow.

Geographic atrophy—atrophy of the retinal pigment epithelium with dropout or degeneration of cellular structure and destruction of the rodsand cones in close opposition to the apex of the RPE. This process ismost commonly seen in dry forms of macular degeneration but can co-existwith exudative wet forms of macular degeneration. Halting theprogression of geographic atrophy is a targeted endpoint for measuringagents effective in treating dry macular degeneration.

1. A method of treating or slowing the development of maculardegeneration in a patient, the method comprising: identifying a patientwith macular degeneration with evidence of choroidal blood flowreduction; and injecting a botulinum neurotoxin into the periorbital orpara orbital region of the patient, but not into an intra-ocular or asubconjunctival region of the patient to increase choroidal blood flow,wherein the botulinum neurotoxin injected conforms with conventionaldosing and preserves or improves vision of the patient.
 2. The method ofclaim 1 further comprising measuring choroidal blood flow of the patientusing Ocular Coherence Tomography with Angiographic capability (OCT-A).3. The method of claim 2, wherein choroidal blood flow includes bloodflow in the choriocapillaris.
 4. The method of claim 1, whereininjecting the botulinum neurotoxin improves uveoscleral pumping on alevel of Bruch's membrane and retinal pigment epithelium.
 5. The methodof claim 1, wherein injecting the botulinum neurotoxin aligns thepatient's retinal pigment epithelium and sustains barrier function ofthe retinal pigment epithelium.
 6. The method of claim 1, whereininjecting the botulinum neurotoxin sustains integrity of the patient'sBruch's membrane.
 7. The method of claim 1, wherein the maculardegeneration is non-exudative or dry macular degeneration.
 8. The methodof claim 7, wherein the dry macular degeneration includes maculardegeneration with geographic atrophy and compromised choroidal bloodflow.
 9. The method of claim 1, wherein the macular degeneration isexudative or wet macular degeneration.
 10. The method of claim 1, wherethe botulinum neurotoxin is injected into the patient using apterygopalatine ganglion target in a para orbital region.
 11. The methodof claim 1, wherein injecting the botulinum neurotoxin avoids diplopiaand/or ptosis.
 12. The method of claim 1, wherein the conventionaldosing ranges between 5-400 units.
 13. The method of claim 1 furthercomprising one or more repeated injections of botulinum neurotoxin intothe patient.
 14. Method of claim 1 further comprising measuring bloodflow of the patient using a laser Doppler technique.
 15. The method ofclaim 1, wherein injecting the botulinum neurotoxin results in areduction in rate of drusen formation, atrophic geographic atrophy,pigment migration, leakage or choroidal neovascularization, or retinalhemorrhage.
 16. The method of claim 1 which wherein injecting thebotulinum neurotoxin avoids risk of retinal detachment endophthalmitis,cataract formation, vitreous hemorrhage, retinal break, and glaucoma.